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1 


BUREAU   OF  THE   CENSUS 
S.  N.  D.  NORTH  ^  DIRECTOR 


TUBERCULOSIS  IN 

THE  UNITED 

STATES 


PREPARED  FOR  THE  INTERNATIONAL  CONGRESS  ON  TUBER- 
CULOSIS, WASHINGTON,  SEPTEMBER  21  TO  OCTOBER  12,1908 


DEPARTMENT  OF  COMMERCE  AND  LABOR 


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Columbia  Wini\}tv&itp   N^O 
in  ttje  Citp  of  J^etn  gorfe 

College  of  l^i)v^itian^  anb  burgeons 


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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/tuberculosisinunOOunit 


PROPORTION  OF  DEATHS  FROM  EACH  SPECIFIED  CAUSE 

IN  THE 
REGISTRATION  AREA  1907 


PhOI0-t.'IMOGR*PHE0S    WASMiNGTON    D   < 


BUREAU   OF   THE    CENSUS 

S.  N.  D.  NORTH  ^  DIRECTOR 

1  UBERCULOSIS  IS 

THE  UNITED 

STATES 

^ 

PREPARED  FOR  THE  INTERNATIONAL  CONGRESS  ON  TUBER- 

CULOSIS, WASHINGTON,  SEPTEMBER  21  TO  OCTOBER  12,  190S 

DEPARTMENT  OF   COMMERCE   AND  LABOR 

8—1413. 
V.  8.  No.  109. 


CENSUS   PUBLICATIONS   ON   MORTALITY  STATISTICS 

SINCE   1900. 


TWELFTH   CENSUS. 

Vital  Statistics,  Part    I — Analysis  and  Ratio  Tables. 

Vital  Statistics,  Part  II — Statistics  of  Deaths. 

Bulletin  No.  15.    A  discussion  of  the  Vital  Statistics  of  the  Twelfth  Census. 

[The  last  of  the  series  of  decennial  reports.  The  data  are  for  the  census  year  end- 
ing May  31,  1900,  and  are  based  upon  enumerators'  returns  from  the  nonregistration 
area  and  upon  transcripts  of  deaths  from  the  registration  records,  chiefly,  for  the 
registration  area.  Succeeding  reports  are  for  the  calendar  years  and  relate  to  the 
registration  area  only.] 


PERMANENT  CENSUS. 


Mortality  Statistics,  1900  to  1904.     Five  years  in  one  volume. 

Mortality  Statistics,  1905.     Sixth  Annual  Report. 

Mortality  Statistics,  1906.     Seventh  Annual  Report. 

Mortality  Statistics,  1907.     Eighth  Annual  Report.     In  preparation. 


PAMPHLETS. 


No.    71.  (Circular)  Registration  of  Deaths. 

No.  100.  Legislative  Requirements  for  Registration  of  Vital  Statistics.  [Out  of  print 
See  Nos.  71  and  104.] 

No.  101.  Practical  Registration  Methods. 

No.  102.  Relation  of  Physicians  to  Mortality  Statistics. 

No.  103.  Medical  Education  in  Vital  Statistics.     [Out  of  print.] 

No.  104.  Registration  of  Births  and  Deaths. 

No.  105.  Statistical  Treatment  of  Causes  of  Death. 

No.  106.  Extension  of  the  Registration  Area  for  Births  and  Deaths. 

No.  107.  Modes  of  Statement  of  Cause  of  Death  and  Duration  of  Illness  upon  Certifi- 
cates of  Death. 

No.  108.  Legal  Importance  of  Registration  of  Buths  and  Deaths. 

No.  109.  Tuberculosis  in  the  United  States. 


Manual  of  International  Classification  of  Causes  of  Death. 

NOTE.-Any  publications  now  in  print  may  be  obtained  upon  application  to  the  Director  of  the 

Census. 


fiufaeniment  Prtetlng  mSut 


u^?, 


CONTENTS. 


Page. 

Letter  of  transmittal — 7 

Vital  statistics  are  the  foundation  of  sanitary  science 8 

Letter  from  President  Roosevelt  accepting  the  presidency  of  the 

International  Congress  on  Tuberculosis 9 

Introductory H 

Purpose  of  tlie  Census H 

Vital  statistics  dependent  upon  enumeration  of  population 11 

The  beginning  of  vital  statistics 11 

Success  and  failure  of  state  registration  laws 12 

Present  constitution  of  registration  area  for  deaths 12 

No  registration  area  for  births 14 

Attempted  national  mortality  statistics 14 

Extension  of  the  registration  area 15 

How  the  Census  aids 15 

L— Some  Facts  in  Regard  to  Tuberculosis  in  the  United  States  from 

THE  Mortality  Statistics  op  the  Census 16-36 

Mortality  statistics  of  the  Census  indispensable 16 

Sources  of  tables 16 

Statistics  for  1907 16 

The  nature  of  tuberculosis 17 

Tuberculosis  (all  forms) 17 

Mortality  of  the  United  States  from  tuberculosis 17 

No  exact  statement  possible 18 

The  President's  estimate 18 

High  mortality  of  the  colored  race  from  tuberculosis 19 

Sparsely  settled  areas 20 

Understatement  of  tuberculosis  in  returns  of  deaths 20 

Difficulty  of  securing  correct  statements  of  deaths  from  tuberculosis 21 

discussion  op  tables. 

Decreasing  death  rates  from  tuberculosis 22 

Overstatement  of  tuberculosis  in  early  statistics 22 

"Proportional  deaths " 23 

Need  of  fully  comparable  international  statistics  of  causes  of  death 23 

Death  rates  of  foreign  countries 24 

How  tuberculosis  kills 24 

Various  forms  of  tuberculosis 24 

Comparison  of  statistical  classifications 25 

Influence  of  sex 25 

City  and  country 26 

Death  rates  at  certain  age  periods 27 

Age  distribution  of  deaths  from  various  forms  of  tuberculosis 27 

Economic  loss  from  tuberculosis 28 

Estimates  of  pecuniary  loss - 28 

(3) 


4  CONTENTS. 

Page. 

I. — Some  Facts  ix  Regasd  to  Tubeecclosis  ix  the  Uxixed  States  frou 
THE  MoRTALiTT  STATISTICS  OF  THE  CENSUS — Continued. 

Economic  value  of  life 29 

Average  age  at  death. 30 

Incidence  of  tuberculosis  upon  the  most  productive  ages 31 

Westergaard's  life  table,  excluding  tuberculosis 31 

Relative  importance  of  tuberculosis  and  other  diseases 32 

Relative  frequency  of  deaths  fi-om  tuberculosis  by  states 34 

Color 34 

Conjugal  condition 34 

Relative  prcA'alence  of  tuberculosis  by  classes  of  occupations 35 

Rates  of  tuberculosis  for  specified  occupations 35 

Occupations  most  subject  to  tuberculosis 35 

Death  rates  from  tuberculosis  i^all  foiTos)  by  states  and  cities,  1907 36 

II. — The  Work  of  the  Bureau  of  the  Cexsus  ix  Vital  Statistics 36-41 

Relation  of  the  Census  to  registration 36 

Duty  of  undertaker,  relative,  and  attending  physician 37 

Duty  of  local  registrar 37 

Duty  of  state  registrar 38 

Transcripts  for  the  Census 38 

Compilation  by  the  Census 38 

Requisites  for  accui'ate  mortality  statistics 39 

Chief  difficulties  in  obtaining  statistics  of  tuberculosis 39 

Cooperation  for  extension  of  registration  area 40 

Resolution  by  the  Congress  of  the  United  States 40 

UnifoiTQ  certificate  of  death  to  be  adopted 41 

UnifoiTii  nomenclatui'e  of  diseases  in  prepai-ation 41 

III. — Hovr    THE   IXTERXATIOXAl   COXGEESS  OX   TUBERCULOSIS  CaX  PrOMOTE 

the  Prevextiox  of  Tuberculosis  bt  Ixsistixg  upox  the  Xecesstty 
for  Complete  Registratiox  of  Deaths  Throughout  the  Uxited 

States : 41-45 

Statistics  of  tuberculosis  a  part  of  general  mortality  statistics 42 

COLLECTIOX   OF    STATISTICS   OF  TUBEECrXOSIS. 

Registration  of  deaths  and  notification  of  sickness  fi-om  tuberculosis 42 

Complete  statistics  are  essential 43 

A.  Indispensable  importance  of  registration  of  sickness  and  deaths  from 
tuberculosis 43 

Preliminary'  draft  of  resolutions  proposed 43 

Accurate  and  internationally  comparable  statistics  of  tuberculosis  required.  44 

B.  Necessity  for  uniform  statistical  classification  and  accurate  reporting  of 
tuberculosis 44 

Preliminary^  draft  of  resolutions  proposed 44 

REFERENCE  TABLES. 

Table  1. — Death  rates  and  proportional  deaths  (to  all  causes)  from  all  forms  of 
tuberculosis  in  the  United  States,  Massachusetts,  and  England  and  Wales, 

for  each,  year  since  the  middle  of  the  last  centmy 49 

Table  2. — Death  rates  from  tuberculosis  of  lungs  in  the  registration  area  of  the 
United  States  and  in  certain  foreign  coimtries  (dui-ing  recent  years) :  1902  to 

1906 52 

Table  8. — Deaths,  death  i-ates,  and  per  cent  of  deaths  from  the  various  forms 
of  tuberculosis  (International  Classification)  in  the  registration  area  of  the 

United  States  (during  recent  years):  1902  to  1907 52 


CONTENTS.  5 

Page. 
Table  4. — Death  rates,  by  sex,  and  as  urban  and  rural,  from  tuberculosis  of 

lungs  for  the  registration  states:  1900  and  1890 53 

Table  5. — Death  rates,  by  sex,  for  the  registration  area  and  registration  states 

(aggregate,  urban,  and  rural)  from  tuberculosis  of  lungs:  1900  and  1890 55 

Table  6. — Proportional  deaths  from  each  form  of  tuberculosis  (International 

Classification)  at  certain  age  periods  for  the  registration  area:  1900  to  1904        55 
Table  7. — Relative  importance  of  tuberculosis  as  a  cause  of  death  at  specified 

age  periods  in  the  registration  area,  1907 : 

{A)  At  all  ages 56 

(B)  Under  15  years  of  age 56 

(C)  From  15  to  29  years,  inclusive 57 

(Z))  From  30  to  44  years,  inclusive 57 

(E)  From  45  to  59  years,  inclusive 58 

(F)  From  60  to  74  years,  inclusive 58 

(G)  Over  75  years  of  age 59 

Table  8. — Relative  importance  of  tuberculosis  as  a  cause  of  death  in  the  regis- 
tration states:  1907 59 

Table  9. — Death  rates  from  tuberculosis  of  lungs  of  white  and  colored,  by  sex, 
for  the  registration  area  and  registration  states  (aggregate,  urban,  and  rural): 
1900  and  1890 60 

Table  10.— Death  rates  from  tuberculosis  of  lungs,  by  conjugal  condition,  at 
certain  age  periods  in  the  registration  area:  1900 60 

Table  11. — Death  rates  from  tuberculosis  of  lungs  and  other  important  causes 
of  death,  by  classes  of  occupations,  in  the  registration  states:  1900 60 

Table  12. — Death  rates  from  tuberculosis  of  lungs,  for  certain  occupations  of 
each  sex  iu  the  registration  states:  1900 65 

Table  13. — Death  rates  from  all  forms  of  tuberculosis  in  the  registration  area,  its 
main  subdivisions,  the  registration  states,  and  cities  of  100,000  population  or 
over  in  1900,  for  each  year  since  the  beginning  of  the  annual  reports  on 
mortality  statistics:  1900  to  1907 66 

DIAGRAMS  AND  ILLUSTRATIONS. 

Page. 

Proportion  of  deaths  from  each  specified  cause  in  the  registration  area:  1907, 

colored  diagram Frontispiece. 

Increase  in  the  number  of  registration  states:  1880,  1890,  1900, 1907,  cartogram.         13 

Standard  certificate  of  death Facing        38 

Facsimile  of  punched  mortality  card Facing        38 

Death  rates  and  proportional  deaths  (to  all  causes)  from  all  forms  of  tubercu- 
losis in  the  United  States,  Massachusetts,  and  England  and  Wales  for  each  year 
since  the  middle  of  the  last  century,  colored  diagram Facing        47 

Consumption — Number  of  deaths  per  100,000  of  population  for  cities  and  rural 

districts  in  the  registration  states:  1900  and  1890,  diagram 54 

Consumption — Number  of  deaths  per  100,000  of  population,  bj^-  color  and  sex: 

1900  and  1890,  diagram 61 

Consumption — Number  of  deaths  per  100,000  of  population  by  conjugal  condi- 
tion and  age  periods,  registration  area:  1900,  diagram 62 

Number  of  deaths  per  100,000  of  population  from  specified  causes  in  the  principal 

occupation  groups:  1900,  diagram 63 

Consumption — Number  of  deaths  per  100,000  of  population  among  persons  10 
years  of  age  and  upward  in  specified  occupations:  1900,  diagram 64 


LETTER  OF  TRANSMITTAL. 


Department  of  Commerce  and  Labor, 

Bureau  of  the  Census, 
Washington,  D.  C,  July  80,  1908. 
Sir: 

This  pamphlet,  the  contents  of  which  will  form  a  part  of  the  eighth 
annual  report  on  mortality  statistics  for  the  year  1907,  is  published 
in  advance  of  the  complete  preparation  of  that  report  in  order  that 
it  may  be  of  use  to  the  International  Congress  on  Tuberculosis  at 
its  session  in  this  city  from  September  21  to  October  12,  1908.  No 
more  important  service  can  be  rendered  by  mortality  statistics  than 
the  compilation  of  data  which  will  prove  of  practical  assistance  to 
those  actively  engaged  in  the  prevention  of  disease.  With  the  awak- 
ening interest  of  the  public  in  sanitation  there  is  arising  an  urgent 
demand,  which  should  be  met,  that  our  mortality  statistics  shall  be 
fully  adequate  for  this  important  purpose. 

This  pamphlet  has  been  prepared  by  Dr.  Cressy  L.  Wilbur,  chief 
statistician  for  vital  statistics  of  the  Bureau  of  the  Census.  The 
diagrams,  together  with  others  contained  in  the  Census  exhibit,  but 
not  reproduced  here,  were  constructed  under  the  direction  of  Mr.  C.  S. 
Sloane,  geographer  of  the  Census. 
Very  respectfully. 


Director. 
Hon.  Oscar  S.  Straus, 

Secretary  of  Commerce  and  Labor. 


VITAL  STATISTICS  ARE  THE  FOUNDATION  OF  SANITARY 
SCIENCE  AND  ABSOLUTELY  NECESSARY  FOR  THE  PREVEN- 
TION OF  TUBERCULOSIS. 


^^Our  Absurd  Vital  Statistics. — ^Vital  statistics  in  this  country  are  an  infant  science. 
Yet  they  are  the  very  basis  and  foundation  of  any  attempt  to  better  the  general  health. 
Knowledge  of  what  is  killing  us  before  our  time  is  the  first  step  toward  saving  our  lives. 
The  Census  Bureau  does  its  best  to  acquire  this  essential  information." — Samuel 
Hopkins  Adams  in  McClure's,  July,  1908. 

'^Resolved,  That  the  achievement  of  the  registration  of  all  deaths,  with  their  causes, 
immediately  after  their  occurrence,  and  the  prompt  retiirn  of  certificates  from  local 
registrars  to  the  central  bureau  of  "vital  statistics,  thereby  giAdng  the  sanitary  authori- 
ties of  the  state  timely  information  of  the  exact  prevalence  and  distribution  of  disease, 

IS  THE  MOST  IMPORTANT  OP  ALL  SANITARY  MEASURES,  AND  SHOULD  BE  UNREMITTINGLY 
URGED  UNTIL  SUCCESSFULLY  CARRIED  OUT  IN  EVERY  STATE  OP  THE  UNION." — Associ- 
ated Health  Authorities  and  Sanitarians  of  Pennsylvania,  1904- 

"Public  hygiene  is  built  upon,  is  controlled  and  directed  by,  and  is  everlastingly 
in  debt  to  vital  statistics.  The  might  and  the  right  to  dnect  the  future  of  preventive 
medicine,  to  make  and  to  terminate  contracts,  to  approve  and  reject  risks,  to  test 
materials  and  methods,  to  invest  means  and  to  distribute  profits,  these  things  belong 
inalienably  to  vital  statistics.  Eveiy  wheel  that  turns  in  the  service  of  public  health 
must  be  belted  to  this  shaft,  otherwise  preventive  medicine  must  remain  invertebrate 
and  unable  to  realize  the  profits  available  from  the  magnificent  offering  of  collateral 
sciences.  If  the  unborn  historian  of  hygiene  in  the  twentieth  centurj^  shall  find  one 
anomaly  more  curious  than  any  other,  it  will  be  that  the  twentieth  century,  opening 
with  prodigious  resources,  immediately  available,  ran  a  third  or  half  its  course  before 
these  resources  became  so  standardized  that  each  unit  of  power  might  be  accounted 
for  in  a  definite  scheme  of  ^ital  statistics." — Dr.  John  S.  Fulton,  then  Secretary  of  the 
State  Board  of  Health  of  Maryland,  now  Secretary-General  of  the  International  Congress 
on  Tuberculosis,  in  an  address,  "Vital  Statistics:  A  Plea  for  Actuarial  Administration 
and  Control  of  the  Great  Resources  of  Preventive  Medicine,"  before  the  American  Public 
Health  Association,  1902. 
(8) 


THE  INTERNATIONAL  CONGRESS  ON  TUBERCULOSIS. 


LETTER  FROM  PRESIDENT  ROOSEVELT. 

The  White  House,  Wasliington,  May  12,  1908. 
To  Dr.  Lawrence  F.  Flick, 

Ohairman,  Committee  on  International  Congress  on  Tuberculosis: 

Sir:  It  is  with  great  pleasure  that  I  accept  the  presidency  of  the 
''International  Congress  on  Tuberculosis"  which  is  to  meet  in  this 
city  on  September  21,  1908,  and  extend  its  session  to  October  12, 
1908.  Official  duties,  however,  may  prevent  my  presiding  at  the 
initial  meeting  of  the  Congress,  in  which  case  I  will  deputize  Secretary 
Cortelyou. 

The  importance  of  the  crusade  against  tuberculosis,  in  the  interest 
of  which  this  Congress  convenes,  can  not  be  overestimated  when  it  is 
realized  that  tuberculosis  costs  our  country  two  hundred  thousand 
lives  a  year,  and  the  entire  world  a  million  lives  a  year,  besides  con- 
stituting a  most  serious  handicap  to  material  progress,  prosperity, 
and  happiness,  and  being  an  enormous  expense  to  society,  most  often 
in  those  walks  of  life  where  the  burden  is  least  bearable. 

Science  has  demonstrated  that  this  disease  can  be  stamped  out,  but 
the  rapidity  and  completeness  with  which  this  can  be  accomplished 
depend  upon  the  promptness  with  which  the  new  doctrines  about 
tuberculosis  can  be  inculcated  into  the  minds  of  the  people  and 
engrafted  upon  our  customs,  habits,  and  laws.  The  presence  m  our 
midst  of  representatives  of  world-wide  workers  in  this  magnificent 
cause  gives  an  unusual  opportunity  for  accelerating  the  educational 
part  of  the  program. 

The  modern  crusade  against  tuberculosis  brings  hope  and  bright 
prospects  of  recovery  to  hundreds  and  thousands  of  victims  of  the  dis- 
ease, who  under  old  teachings  were  abandoned  to  despair.  The  work 
of  this  Congress  will  bring  the  results  of  the  latest  studies  and  mvesti- 
gations  before  the  profession  at  large,  and  place  in  the  hands  of  our 
physicians  all  of  the  newest  and  most  approved  methods  of  treating 
the  disease — a  knowledge  which  will  add  many  years  of  valuable  life 
to  our  people  and  will  thereby  mcrease  our  public  wealth  and  hap- 
piness. 

(9) 


10  TUBERCULOSIS    IN   THE    UNITED    STATES. 

The  International  Congress  on  Tuberculosis  is  in  the  interest  of 
universal  peace.  By  joining  in  such  a  warfare  against  a  common  foe 
the  peoples  of  the  world  are  brought  closer  together  and  made  to  better 
realize  the  brotherhood  of  man;  for  a  united  interest  against  a  com- 
mon foe  fosters  universal  friendship.  Our  country,  which  is  honored 
this  year  as  the  host  of  other  nations  in  this  great  gathering  of  leaders 
and  experts,  and  as  the  custodian  of  the  magnificent  exhibit  which 
will  be  set  up  by  the  entire  world,  should  manifest  its  appreciation  by 
giving  the  Congress  a  setting  worthy  of  the  cause,  of  our  guests,  and 
of  ourselves.  We  should  endeavor  to  make  it  the  greatest  and  the 
most  fruitful  Congress  which  has  yet  been  held,  and  I  assure  you  of 
my  interest  and  services  to  that  end. 

With  expressions  of  appreciation  for  the  comphment  conferred  in 
extending  the  invitation  to  become  president  of  the  Congress, 
Very  respectfully, 

Theodore  Roosevelt. 


TUBERCULOSIS  IN  THE  UNITED  STATES. 


INTRODUCTORY. 

The  Census  of  the  United  States  was  primarily  constituted  for  the 
purpose  of  making  a  decennial  enumeration  of 
population  so   that  the  representation  of  the 

various  states  in  the  lower  house  of  Congress  might  be  apportioned 
properly.  The  First  Census  was  taken  in  1790,  and  a  decennial 
census  has  been  taken  every  tenth  year  since  that  time;  the  last,  for 
the  year  1900,  was  the  Twelfth  Census,  and  the  next  one,  the  Thir- 
teenth Census,  for  which  plans  are  already  being  made,  will  be  for 
the  year  1910. 

A    correct    enumeration    of   population,   at    sufficiently   frequent 
intervals,  is  absolutely  essential  to  the  proper 
presentation  of  vital  statistics,  and  hence  the       ^"^^  ''''''''":'  ^^^P^^deat 

,  ..  ,i,.i  11         11       upon  enumeration  of  popula- 

constitutional  provision  that  the  people  should    ^j^^ 

be  counted  every  ten  years  may  be  considered 

to  have  laid  a  part  of  the  foundation  of  vital  statistics,  and  therefore 

of  modem  preventive  medicine,  in  the  United  States. 

It  was  not  enough,  however,  merely  to  enumerate  the  population 
at  regular  intervals,  but  at  an  early  date  the 

importance  of  vital  statistics  to  the  people  of  .  .  ^  egmnmg  o  yi  a  s  a- 
the  United  States  was  realized,  and  an  effort  was 

made  to  secure  such  statistics  in  connection  with  the  other  Census 
inquiries.  England  began  a  comprehensive  series  of  "Annual 
Reports  of  the  Registrar-General  of  Births,  Deaths,  and  Marriages" 
in  1837,  from  which  period  dates  the  beginning  of  modem  sanitation. 
Other  European  countries  soon  followed  her  example,  until,  at  the 
present  time,  there  is  scarcely  a  civilized  nation  upon  the  globe — 
except  the  United  States  of  America — but  possesses  a  complete 
official  registry  of  the  vital  events  of  its  people.  The  movement  was 
felt  in  the  United  States.  The  "First  Annual  Report  of  the  Secre- 
tary of  the  Commonwealth  to  the  Legislature:  Under  the  Act  of 
March,  1842,  relating  to  the  Registry  and  Returns  of  Births,  Mar- 
riages, and  Deaths  in  Massachusetts"  was  published  in  1843,  and  the 
annual  volumes  have  been  continued  regularly  down  to  the  present 
time.  Every  citizen  of  the  United  States,  as  well  as  every  citizen  of 
Massachusetts,  should  take  interest  and  pride  in  these  reports,  for 
they  are  nearly  all  that  we  have  in  the  way  of  a  continuous  history  of 

(11) 


12  TUBERCULOSIS   IN    THE    UNITED   STATES. 

the  movement  of  population  and  the  variations  in  the  vital  statistics 
of  any  considerable  portion  of  the  American  people  for  the  last  half  of 
the  nineteenth  century. 

Other  states  attempted  to  follow  the  example 

Success  and  failure  of  state         n   -kit  i  i_.  •i',i,,i 

registration  laws.  ^f  Massachusetts,  as  summarized  m  the  tenth 

annual  report  of  that  state: 

As  observed  above,  the  law  in  this  state  was  passed  in  1842.  This  law  was  modified 
and  improved  by  the  act  of  March  16,  1844,  and  still  further  by  the  act  of  May  2,  1849. 
The  state  of  New  York  followed  with  a  registration  law,  passed,  April  28,  1847,  and 
made  their  first  report  in  April,  1848.  New  Jersey  passed  a  law  on  the  subject  March, 
1848,  and  remodeled  it  with  improvements  by  the  act  of  March  19,  1851.  Their  report 
before  us  bears  date  of  February,  1852.  The  registration  law  of  Connecticut  passed, 
June  24,  1848.  We  have  their  three  reports;  the  last  is  dated  May,  1852.  New 
Hampshire  passed  a  less  efllcient  law,  July  7,  1849,  and  altered  it  without  much 
improvement,  July  4,  1851.  The  act  in  Pennsylvania  on  this  subject  passed  the  legis- 
lature of  that  state,  April  14,  1851,  and  became  a  law  without  the  signatm'e  of  the 
governor,  as  certified  by  the  proper  authorities,  January  12,  1852.  Dming  the  last 
session  of  the  legislature  that  body  manifested  their  approbation  of  it  by  appropriating 
$4,500  to  put  the  law  into  operation.  On  the  9th  of  January,  1852,  the  legislatm'e  of 
Kentucky  passed  a  registration  law,  and  the  subject  will  come  from  influential  sources 
before  the  next  legislature  of  South  Carolina. 

This  was  the  somewhat  hopeful  condition  of  the  movement  for 
registration  of  vital  statistics  in  the  United  States  over  half  a  century 
ago,  but  the  results  were  not  commensurate  with  the  expectations 
entertained  at  that  time.  The  original  New  York  law  was  a  total 
failure,  and  no  other  effort  was  made  in  that  state  until  nearly  forty 
years  later  when  the  excellent  system  planned  by  Dr.  Elisha  Harris 
went  into  effect.  Massachusetts  and  New  Jersey  were  the  only  states 
of  the  original  ''registration  area"  as  constituted  for  the  mortality 
statistics  of  the  Tenth  Census,  1880.  All  of  the  New  England  states 
are  now  included,  the  last  to  be  admitted  being  Maine,  whose  law 
dates  from  1891.  The  early  Pennsylvania  law  was  a  dead  letter,  and 
later  attempts  at  registration  were  futile  until  the  enactment  of  the 
excellent  law  of  1905,  whose  results  justified  the  admission  of  the  state 
to  the  registration  area  in  1906.  During  the  session  of  1908  the  legis- 
lature of  Kentucky  failed  to  act  upon  a  registration  bill,  and  no 
effective  law  for  tliis  purpose  yet  exists  in  any  Southern  state. 

The  net  results  of  the  unassisted  efforts  of  the  states  to  secure  the 
adoption   and   enforcement   of   adequate   regis- 

Present    constitution    of   tratiou  laws  may  be  seen  in   the  Hst  of   those 

registration  area  tor  deaths.  i        c  i  •  •  i«        i 

accepted  for  the  registration  area  or  the 
Twelfth  Census,  1900,  as  having  at  least  fairly  complete  (90  per  cent) 
registration  of  deaths: 

Connecticut.  New  Jersey. 

Maine.  New  York. 

Massachusetts.  Rhode  Island. 

Michigan.  Vermont. 
New  Hampshire. 


14  TUBERCULOSIS  IN   THE   UNITED   STATES. 

To  this  limited  list  Indiana  was  added  in  the  year  1900,  and  in 
1906  the  states  of  California,  Colorado,  Maryland,  Pennsylvania,  and 
South  Dakota  were  accepted,  so  that  at  present  there  are  fifteen  of  the 
forty-six  states  of  the  Union  included  therein.  The  District  of  Co- 
lumbia, which  is  coterminous  with  the  city  of  Washington,  is  regarded 
as  a  registration  city  rather  than  as  a  registration  state,  and  with  76 
other  registration  cities  in  nonregistration  states  helps  to  raise  the 
total  population  of  the  registration  area,  according  to  the  estimate 
for  1907,  to  41,758,037,  or  48.8  per  cent  of  the  total  population  of 
the  United  States. 

The  above  statements  relate  to  the  registration  of  deaths.  There 
is  as  yet  no  registration  area  for  births,  because 

No    registration    area    for    j^     jg     j^q^     ^^^     knOWn     that     any    Statc     in     this 
births.  -^  -11.  •  • 

country  has  succeeded  m  registermg  even  90 
per  cent  of  the  births  that  actually  occur  within  its  limits.  The  rea- 
sons for  this  are  stated  in  the  Census  Report  on  Mortality  Statistics, 
1906  (page  16),  and  also  in  the  pamphlet  on  the  ''Legal  Importance 
of  Registration  of  Births  and  Deaths,"  copies  of  which  will  be  dis- 
tributed at  the  International  Congress  on  Tuberculosis  in  connection 
with  the  present  publication.  It  should  be  remembered  that  on 
account  of  the  entire  absence  of  effective  registration  of  births  in  this 
country,  valuable  data  that  would  be  of  service  to  the  Congress  and 
to  all  who  are  concerned  in  the  prevention  of  tuberculosis  and  other 
diseases  are  entirely  wanting.  It  is  impossible  to  present  any  state- 
ment of  infant  mortality  from  tuberculosis,  some  forms  of  which  are 
especially  fatal  to  infants  and  young  children,  because  there  is  no 
total  number  of  living  births  upon  which  to  base  the  ratio. 

The  success  of  some  of  the  systems  of  state  registration  and  the 

increasing  reahzation  of  the  importance   of  a 
Attempted    national   kj^owlcdge  of  mortality  statistics  with  respect  to 

mortality  statistics-  .  °     .  ^         -'  ^        ^ 

their  practical  sanitary  uses  led  to  the  incorpora- 
tion of  tliis  subject  as  one  of  the  inquiries  of  the  Seventh  Census  (1850). 
It  has  been  retained  in  each  of  the  decennial  enumerations  since  that 
time.  The  method  adopted  was  unfortunate,  namely,  the  enumeration 
of  deaths  after  the  close  of  the  year  by  the  Census  enumerators.  It 
was  well  understood  by  the  Census  authorities  that  satisfactory  results 
could  not  be  obtained  by  such  means.  As  stated  by  Gen.  Francis  A. 
Walker,  Superintendent  of  the  Tenth  Census,  1880  (Compendium, 
Part  I,  page  xxxiii),  "In  truth,  however,  the  statistics  of  mortality 
obtained  through  the  census  have  always  been  defective,  and  often 
grossly  misleading."  This  was  to  be  expected,  because  the  ordinary 
census  method  of  enumeration,  which  is  properly  used  for  population 
which  can  be  counted  at  a  given  time,  is  totally  inapplicable  to  the 
collection  of  data  concerning  vital  events,  such  as  births,  deaths,  and 
marriages.     If  accurate  statistics  are  to  be  obtained,  these  events 


TUBERCULOSIS  IN   THE   UNITED   STATES.  15 

must  be  registered  immediately  after  their  occurrence,  and  under  laws 
which  provide  penalties  for  neglect. 

The  true  mortality  statistics  of  the  United  States  began  with  the 
establishment  of  the  "registration  area/'  at  first 
consisting  only  of  two  states  and  twenty  cities,  in    .  Extension  of  the  registra- 

®  ♦^  ,  .  tion  area. 

1880.  It  has  progressed  so  far  that  we  are  qmte 
justified  in  recommending  that  the  futile  attempt  at  a  decennial 
enumeration  of  deaths  be  discontinued,  and  that  sole  dependence  be 
placed  upon  the  results  of  immediate  registration  of  deaths  under 
proper  state  laws  effectively  enforced.  A  very  important  part  of  the 
duty  of  the  Bureau  of  the  Census  since  its  permanent  organization  in 
1902 — such  work  was  quite  out  of  the  question  under  the  old  system 
whereby  the  Census  Office  was  completely  disorganized  or  nonexistent 
during  the  interdecennial  years — is  extension  work;  that  is,  cooper- 
ation with  the  sanitary  authorities  of  nonregistration  states,  and  with 
such  great  national  organizations  as  the  American  Medical  Associa- 
tion, the  American  Public  Health  Association,  and  the  Conference  of 
Commissioners  on  Uniform  State  Laws,  for  the  purpose  of  securing 
adequate  registration  laws.  A  model  bill  for  this  purpose,  indorsed 
by  the  national  associations  and  by  the  Bureau  of  the  Census,  will 
be  presented  to  the  legislatures  of  nonregistration  states  at  their  next 
sessions.  In  addition  to  the  new  registration  states  added  in  1906, 
several  other  states,  namely,  Minnesota,  Montana,  Nebraska,  North 
Dakota,  Ohio,  Utah,  Washington,  and  Wisconsin,  have  recently 
adopted  laws  whose  results  are  now  under  observation. 

How  the  Census  aids  in  this  work  may  be  learned  from  some  of 
the  pamphlets  found  in  the  list  of  publications 

/  r.\        rrn  -J  "j.  it  How  the  Census  aids. 

(page  2) .     1  he  more  rapid  its  progress  the  sooner 

will  come  the  time  when  Americans  will  possess  vital  statistics  which 
cover  the  entire  country,  and  of  which  they  need  no  longer  be  ashamed 
in  comparison  with  those  of  other  nations.  For  no  amount  of  devoted 
work  on  the  part  of  those  immediately  in  charge  of  the  subject  of 
mortality  statistics  in  the  Census — and  the  names  of  Dr.  Edward 
Jarvis,  Dr.  John  S.  Billings,  and  Mr.  William  A.  King  are  honored 
among  the  vital-statisticians  of  the  world — can  make  up  for  the 
absence  of  materials  for  their  labors.  So  long  as  present  conditions 
continue  the  United  States  must  stand  in  the  eyes  of  the  world  as 
practically  a  nonregistration  country — a  country  having  only  par- 
tial registration.  The  Census  can  do  nothing  directly  to  remedy  this; 
the  registration  of  births  and  deaths  is  entirely  dependent  upon  state 
and  city  laws.  When  the  people,  who  are  affected  by  the  failure  or 
absence  of  such  laws,  shall  come  to  see  their  importance,  there  will  be 
a  rapid  extension  of  effective  registration,  and  the  United  States  will 
no  longer  be  compelled  to  confess  failure  in  one  of  the  requisites  of 
modem  government,  the  proper  registration  of  vital  statistics. 


16  TUBEKCULOSIS   IN    THE   UNITED   STATES. 

I. — Some  Facts  in  Regard  to  Tuberculosis  in  the  United  States 
FROM  the  Mortality  Statistics  of  the  Census. 

Incomplete  as  they  are,  the  mortahty  statistics  of  the  Census  form 

the  only  source  of  information  in  regard  to  the 

Mortality  statistics  of  the   act.ual    prevalence    of    tuberculosis    and    other 

Census  indispensable.  -^.^^^..^  .. 

diseases  m  the  united  States  or  any  consider- 
able portion  of  it,  apart  from  the  data  presented  for  individual  states 
and  cities  in  their  annual  registration  reports.  These  reports  vary 
greatly  in  their  quality,  and  present  such  marked  differences  in  the 
methods  of  compilation  that  it  is  extremely  difficult  for  any  person 
except  a  statistical  expert  to  prepare  comparable  tables  from  them. 
For  a  general  examination  of  the  occurrence  of  tuberculosis,  even  as 
restricted  to  the  states  of  the  registration  area,  it  is  therefore  neces- 
sary to  resort  to  the  compilations  made  by  the  Bureau  of  the  Census, 
which  present  the  data  with  absolute  uniformity  so  far  as  method 
of  compilation  is  concerned,  and  with  all  of  the  accuracy  that  is 
obtainable  from  the  original  returns. 

The  tables  themselves,  for  the  most  part,  will  be  presented  at  the 
end    of    the    pamphlet,    where    they   may   be 

ources  o  ta  as.  referred    to    conveniently   in   connection    with 

the  present  brief  text,  which  is  intended  only  to  point  out  some 
salient  features.  Their  sources  are  chiefly  the  two  volumes  on  Vital 
Statistics  of  the  Twelfth  Census,  1900,  which  present  comparative 
figures  for  the  census  years  ending  in  1900  and  1890,  and  the  last  pub- 
lished volume  of  the  series  of  annual  reports,  which  began  with  the 
calendar  year  1900.  The  tables  in  the  latter  (Mortality  Statistics, 
1906)  give  comparative  rates  for  several  recent  years  (1902  to  1905) 
and  a  quinquennial  average  (1901  to  1905)  for  the  purpose  of  con- 
venient reference.  It  is  not  worth  while,  as  a  rule,  to  make  any  com- 
parison with  the  rates  for  the  registration  area  of  the  Tenth  Census, 
1880,  because  this  area  was  so  small  and  so  largely  urban  in  character 
that  it  can  not  be  taken  as  fairly  comparable  with  the  registration 
areas  of  1890,  1900,  and  later  years. 

Statistics  for  1907  from  the  annual  report  which  is  now  in  prepara- 
tion and  will  be  published  very  shortly,  have 
or  1907.  been   introduced   in   many    of   the   tables.     It 

should  be  remembered  that  the  present  text  and  the  illustrative 
diagrams  were  necessarily  prepared  some  time  before  the  meeting  of 
the  International  Congress  on  Tuberculosis,  and  hence  it  was  neces- 
sary to  use  the  data  at  hand  at  that  time,  the  latest  published  being 
those  contained  in  the  annual  report  for  1906.  Tuberculosis  does  not 
as  a  rule  show  marked  fluctuations  from  year  to  year,  and  hence  the 
statistics  for  the  year  1906  may  be  taken  equally  with  those  for  1907 
as  representing  present  conditions. 


TUBERCULOSIS   IN    THE    UNITED   STATES.  17 

The  first  question  that  naturally  presents  itself  is,  What  is  tuber- 
culosis? The  word  "  tuberculosis"  is  of  com- 
paratively recent  vogue  in  vital  statistics  and  ^J^"  "^^"'«  ^^  '"^"'="" 
in  general  medical  and  popular  usage.  As  re- 
cently as  the  Twelfth  Census,  1900,  the  official  term  employed  in  the 
mortality  statistics  for  tuberculosis  of  the  lungs  was  "consumption." 
In  the  earlier  statistics  "consumption,"  or  "phthisis,"  was  regarded 
as  a  local  disease  of  the  lungs,  and  other  forms  of  tuberculosis  were 
elsewhere  classified  in  connection  with  the  organs  or  parts  of  the  body 
affected.  The  present  conception  of  tuberculosis  is  that  of  a  general 
infectious  disease,  capable  of  affecting  all  parts  of  the  human  body, 
but,  in  whatever  situation  found,  caused  by  the  Bacillus  tuberculosis, 
the  "germ"  which  was  discovered  by  Robert  Koch  in  1882.  It  is  a 
general  disease,  because  it  may  affect  the  entire  organism;  and  it  is 
an  infectious,  or  infective,  disease,  because  it  may  be  communicated, 
either  directly  or  indirectly,  from  a  person  ill  with  it  to  a  healthy 
person,  by  means  of  the  bacillus  that  causes  it.  But  it  is  not  a  con- 
tagious disease,  in  the  sense  that  smallpox  and  scarlet  fever  are 
actively  contagious  or  transmissible  by  mere  contact;  and  it  is  a 
cruel  injustice  to  tuberculous  persons  who  take  proper  precautions  in 
regard  to  the  destruction  or  disinfection  of  their  sputa,  to  treat  them 
with  the  abhorrence  that  is  usually  associated  with  leprosy  and 
smallpox. 

The  present  tendency  in  mortality  statistics  is  to  deal  with  the  total 
nunaber  of  deaths  from  tuberculosis,  so  far  as 
obtainable,  and  it  is  therefore  necessary  in  Tuberculosis  (all 
employing  the  older  statistical  tables  to  con- 
solidate the  deaths  compiled  under  the  various  forms  formerly  in  use, 
such  as  "consumption"  (tuberculosis  of  lungs),  "scrofula  and  tabes" 
{tuberculosis  of  lymphatic  glands  and  abdominal  tuberculosisO ,  and 
"hydrocephalus"  (tuberculous  meningitis),  in  order  to  obtain  the 
number  of  deaths  from  tuberculosis  {all  forms),  which  is  stated  when- 
ever possible.  The  International  Classification  of  Causes  of  Death, 
which  was  adopted  by  the  Census  beginning  with  the  statistics  for 
the  calendar  year  1900,  brings  many  of  the  forms  of  tuberculosis 
together,  but  even  yet  does  not  include  "scrofula;"  the  number  of 
deaths  thus  returned,  however,  is  insignificant;  and  the  title  will  prob- 
ably be  abolished  at  the  decennial  revision  which  occurs  next  year. 

The  next  question  that  would  naturally  occur  to  a  person  interested 
,n  the  prevention  of  tuberculosis  in  this  coun- 
try is.  What  is  the   mortality— the  total  number   ^  Mortality  in  the  United 

J,    -,        -,  -,-,_  ^  ^      .       States  from  tuberculosis. 

rf  deaths  ana  the  death  rate — -from    tuberculosis 

n  the    United  States?     This  knowledge  is  very  needful,  because  it 


*  Title  No.  29,  Tuberculose  abdominale,  of  the  International  Classification;  itself  an 
»bjectionable  term,  for  which  tuberculous  peritonitis  could  perhaps  preferably  be 
ubstituted. 

53046—08 2 


18  TUBERCULOSIS  IX  THE  UNITED  STATES. 

would  inform  us  of  the  importance  of  the  disease  at  the  present  time 
and  enable  us  to  know,  by  means  of  future  comparisons,  whether  the 
restrictive  work  inaugurated  by  the  International  Congress  on  Tuber- 
culosis is  bearing  practical  fruit  in  lives  saved  from  this  disease. 
It  is  necessary  to  confess  frankly  that  an  exact  answer  can  not  be 
given    to    this    question.     Neither     the     total 
No  exact  statement  possi-   n^niber  of  deaths  in  the  United  States   from 

Die. 

tuberculosis  (or  any  other  disease)  can  be 
stated  for  any  year,  nor  can  the  death  rate,  which  is  dependent  upon 
an  exact  registry  of  all  deaths  from  this  cause,  be  given.  Until  the 
United  States  shall  possess  an  effective  system  of  registration  of  vital 
statistics  such  absolutely  necessary  data  can  not  be  obtained. 

In  the  absence  of  facts,  and  only  in  the  absence  of  facts,  estimates 

may  be    permissible.     In   his  letter    accepting 

The  President's  estimate.        ,i  •  ^  i>     l^         -r    ,  ,  •  i/^ 

the  presidency  or  the  International  Congress 
on  Tuberculosis  the  President  of  the  United  States  has  referred  tc« 
the  loss  of  two  hundred  thousand  lives  a  year  in  our  country  from^ 
this  cause.  The  statement  is  a  reasonable  one  and  probably  well 
within  the  limits  of  precision  attaching  to  any  estimate.  For  the 
year  1907  there  were  registered  and  returned  to  the  Bureau  of  the 
Census  from  the  states  and  cities  of  the  registration  area,  having 
an  estimated  population  of  41,758,037,  or  48.8  per  cent  of  the  total 
population  of  continental  United  States,  76,650  deaths  from  the 
various  forms  of  tuberculosis  recognized  by  the  International  Classi- 
fication. If  it  is  assumed  that  the  death  rate  from  tuberculosis  for 
that  part  of  the  country  not  covered  by  registration  returns  was  equal 
to  that  ascertained  for  the  registration  area,  then  the  number  of 
deaths  that  occurred  in  the  entire  United  States  in  1907  would  be 
about  double  the  number  reported,  or  approximately  153,000.  But 
it  is  reasonable  to  suppose  that  the  death  rate  from  tuberculosis  for 
the  nonregistration  area  may  have  been  higher  than  that  for  the 
registration  area.  The  map^  showing  the  relative  proportion  of 
deaths  from  consumption  during  the  census  year  1900  in  cUfferent 
state  groups  per  1,000  deaths  from  kno^^^l  causes  does  not  present  £> 
maximum  mortality,  as  indicated  by  the  heaviest  coloring  employed^ 
for  any  portion  of  the  present  registration  area  except  Cahfornia, 
western  and  central  South  Dakota  (very  sparse  population  and  high 
Indian  tuberculosis  rate),  eastern  Colorado,  and  the  Ohio  River  belt 
of  counties  in  Indiana.  For  the  nonregistration  area,  on  the  other 
hand,  we  find  maximum  relative  prevalence  of  tuberculosis  in  Nevada, 
Arizona,  northern  jMissouri,  the  Gulf  counties  of  Alabama  and 
Mississippi,  the  central  counties  of  North  Carolina  and  South  Carohna, 
and  all  of  the  states  of  Kentucky,  Tennessee,  Virginia,  and  West 
Virginia.     Moreover  the  mortality  of  the  colored  population  is  much 

1  Vital  Statistics,  Twelfth  Census,  Plate  No.  18. 


TUBEECULOSIS  IN   THE  UNITED  STATES. 


19 


higher  than  that  of  the  white  population  from  this  disease,  as  indi- 
cated by  Table  9  (page  60),  and  also  by  the  subjoined  table  from 
Mortahty  Statistics,  1907: 


NUMHER  OF  DEATFTS 
FROM  TUBERCULOSIS 
OF  LUNGS  PER  100,000 

OF  population: 
1907. 


White. 


Colored. 


Maryland,  rural. . 
Washington,  D.  C 

Louisville,  Ky 

New  Orleans,  La. 

Baltimore,  Md 

Kansas  City,  Mo. . 
Memphis,  Tenn . . . 


106.  r> 
153.  6 
161.0 
231.6 
182.2 
129.3 
118.3 


2.30.  2 
448.0 
328.  1 
498.0 
498.2 
679.8 
249.7 


The  rates  given  above  indicate  that  the  negro  death  rate  fi'om 
tuberculosis  of  the  lungs  is  markedly  higher  than      ,,.  ,  ,.       ,     , 

,       .  .    .    °,  High     mortahty     of     the 

the  white  death  rate,  not  only  m  cities  but  also  colored  race  from  tubercu- 
in  rural  districts,  of  which  Maryland  affords  the  ^°^'^' 
only  example.  It  is  probable,  moreover,  that  the  registration  of 
deaths  is  somewhat  incomplete  in  rural  Maryland;  it  is  known  to  be 
practically  worthless  in  certain  counties  of  that  state,  while  in  all  of 
them  the  registration  of  the  deaths  of  negroes  is  probably  not  so 
thorough  as  the  registration  of  the  deaths  of  white  persons.  Hence  a 
higher  mortality  from  pulmonary  tuberculosis  may  fairly  be  assumed 
for  all  of  the  negro  population  than  that  for  the  corresponding  white 
population.  There  were  in  the  registration  area  as  constituted  in  the 
census  year  1900  only  1,180,546  negroes,  or  4.1  per  cent  of  the  total 
population.  Subtracting  these  from  the  8,833,994  negroes  in  con- 
tinental United  States  in  1900,  we  have  7,653,448  negroes  in  the  non- 
registration area  in  1900.  No  notable  addition  of  negro  population  has 
been  made  to  the  registration  area  since  that  date,  except  Maryland 
exclusive  of  Baltimore,  Annapolis,  and  Frederick,  representing  a  net 
increase  of  131,862  negro  population  as  enumerated  in  1900.  The 
death  rate  of  the  total  white  and  colored  population  of  the  registration 
area  from  tuberculosis  of  the  lungs  was  158.9  per  100,000  for  the  year 
1907.  If  we  subtract  this  rate  from  the  rate  shown  for  the  colored 
inhabitants  of  the  mral  part  of  Maryland  (230.2  per  100,000),  and 
apply  the  difference  (71.3  per  100,000)  to  the  negroes  of  the  nonregis- 
tration area  enumerated  in  1900,  we  shall  find  a  probable  increase  of 
about  5,500  deaths  a  year  from  pulmonary  tuberculosis  alone.  Con- 
sidering the  imperfect  registration  of  deaths  in  rural  Maiyland,  the 
additional  deaths  from  other  forms  of  tuberculosis,  and  the  increase 
of  the  negro  population  since  1900,  perhaps  from  10,000  to  15,000 
more  deaths  of  colored  persons  from  all  forms  of  tuberculosis  would 


20  TUBERCULOSIS  loST   THE   UNITED   STATES. 

be  added  to  the  returns  on  account  of  the  greater  relative  negro  mor- 
tahty  from  tuberculosis  if  we  had  effective  registration  in  the  South. 
This  is  in  addition  to  the  number  corresponding  to  the  average  death 
rate  (white  and  colored)  of  the  registration  area  (183.6  per  100,000). 
The  chief  objection  that  can  be  urged  against  the  view  that  the 
number  of  deaths  from  tuberculosis  in  the  non- 

Sparsely  settled  areas.  -ij.'  •iii  ijijr 

registration  area  considerably  exceeds  that  of 
the  registration  area  is  that  the  former  contains  much  sparsely  settled 
territory,  and  that  it  is  well  known  that  the  mortality  from  tubercu- 
losis increases  with  the  crowding  together  of  people.  On  the  other 
hand,  the  inhabitants  of  sparsely  settled  regions  form  a  comparatively 
small  aggregate  of  population,  and  in  many  localities  of  this  class,  as 
in  Arizona,  New  Mexico,  Florida,  and  Texas,  there  is  a  considerable 
influx  from  other  states  of  invalids  suffering  from  tuberculosis,  whose 
deaths,  when  they  occur,  are  not  charged  to  the  states  in  which  the 
disease  originated. 

Finally,  there  is  a  large  margin  of  possible  error  and  probably  of 

understatement   in   the   recorded   deaths   from 
Understatement  of  tuber-   tuberculosis  cvcu  in  the  registration  area.     How 

culosis  m  returns  or  deaths.  tip  i  i  i      •     i 

many  deaths  from  pulmonary  tuberculosis  have 
been  reported  as  due  to  "heart  failure,"  "  congestion  of  lungs,"  "  debil- 
ity," "inanition,"  "marasmus,"  and  the  like?  Many  deaths  from 
''chronic  bronchitis"  and  "bronchopneumonia"  are  really  due  to 
tuberculous  infection.  A  majority  of  the  cases  of  acute  serofibrinous 
pleurisy  are  tuberculous  (Osier),  and  many  of  the  deaths  reported 
from  "hemorrhage" — practically  all  of  those  from  "hemorrhage  of 
the  lungs" — are  those  of  tuberculous  persons.  Keports  of  deaths 
from  "lung  trouble,"  "heart  disease,"  and  in  fact  any  form  of  disease, 
may,  either  through  ignorance  or  intention,  conceal  deaths  from 
tuberculosis.  At  least  the  proportional  number  (11.2  per  cent)  of 
deaths  from  tuberculosis  to  deaths  from  all  Icnovjn  causes  would  also 
apply  to  the  ill-defmed  or  unspecified  causes.  Dr.  J.  W.  Irwin,  phy- 
sician to  the  Henry  Pliipps  Institute  ^  of  Philadelphia,  gives  a  long 
list  of  causes  of  death  registered  in  Philadelphia  that  he  considers  to 
be  "probably  tuberculosis."  Among  these  are:  Abscess  of  chest,  hip, 
lungs;  iliac,  lumbar,  pleural,  and  psoas  abscess;  asthma;  congestion 
of  brain,  chest,  lungs;  debility;  disease  of  brain,  chest,  hip,  lungs; 
drops}^  of  brain,  chest,  lungs;  empyema;  brain  fever;  inflammation 
of  brain,  hip,  larynx;  marasmus;  tabes  mesenterica,  etc.  Among  the 
"possibly  tuberculosis"  are:  Cachexia;  cerebro-spinal  meningitis; 
cholera  infantum ;  convulsions;  cyanosis;  diarrhea;  diseases  of  spine; 
typhoid  fever  [a  certain  proportion] ;  inflammation  of  bronchi,  chest, 

^  First  annual  report,  page  89. 


TUBERCULOSIS  IN   TUE   UNITED   STATES.  21 

lungs,  peritoneum,  pleura,  spine,  stomach,  and  bowels;    influenza; 
teething;  whooping  cough. 

Does  the  list  seem  extreme  ?     Is  it  possible  that  physicians  legally 
authorized  to  practice  medicine  Avill  make  such      _._   , 

•  p        1        ^    1       J^    p  ji  !•  Difficulty  of  securing  cor- 

retums  m  cases  or  actual  death  ti'om  tuberculosis,  rect  statements  of  deaths  from 
and  that  the  registration  officials  will  gravely  tuberculosis. 
accept  such  certificates  and  compile  them  as  official  statistics?  In 
regard  to  the  latter  point,  most  registration  offices  are  compelled  to 
accept  what  they  can  get;  the  attending  pliysician  is  the  sole  arbiter 
as  to  what  shall  be  said  or  not  be  said  upon  the  certificate  of  death. 
And  the  absence  of  any  standard  nomenclature  of  diseases  in  this 
country  renders  it  difficult  for  even  the  careful  and  intelligent  physi- 
cian to  know  how  to  report  the  cause  of  death  in  many  cases.  Add 
to  this  the  protean  forms  of  tuberculosis,  the  difficulty  of  its  diagnosis 
in  some  cases,  the  unwillingness  of  the  attending  phj^^sician  to  sign  the 
certificate  of  death  of  a  patient  whose  illness  from  this  disease  he  may 
have  failed  to  report  as  required  by  law,  and  perhaps  the  fact  that  the 
occurrence  of  the  death  from  this  cause  may  be  thought  undesirable 
as  a  matter  of  record  by  the  friends  or  relatives,  or  may,  perchance, 
conflict  with  representations  made  in  applications  for  policies  of 
insurance — there  are  reasons  enough  why  many  deaths  from  tuber- 
culosis should  not  be  reported  and  hence  not  be  compiled  under  this 
cause.  Every  registrar  is  familiar  with  such  cases.  A  careful  and 
fairly  conservative  estimate  worked  out  along  this  line  on  the  basis 
of  the  total  number  of  deaths  registered  in  the  registration  area  and 
enumerated  in  the  nonregistration  area  during  the  last  decennial 
census  year — with  allowance  for  increase  of  population  and  incom- 
plete total  number  of  deaths — showed  that  about  190,000  deaths 
might  fairly  be  considered  to  have  occurred  in  the  United  States  dar- 
ing the  year  1907  from  tuberculosis  or  from  causes  that  might  be 
considered,  in  the  proportion  assigned,  as  "probably  tuberculosis." 

DISCUSSION    OF    TABLES. 

Only    the   most   important    general   indications    relating    to    the 
incidence    of    tuberculosis    are    shown    in    the 
brief    series    of    tables    presented.     For    more      Reference  tables  beginning 

.  .      .  '^^  P3ge  49- 

detailed  data,  and  especially  for  statistics 
relating  to  individual  localities,  reference  should  be  made  to  the 
original  reports,  which  are,  chiefly,  the  Vital  Statistics  of  the  Twelfth 
Census,  1900,  and  the  annual  reports  on  Mortality  Statistics,  1900  to 
1904  (published  in  one  volume),  1905,  and  1906.  Mortality  Statis- 
tics, 1907,  is  in  preparation  and  Avill  be  issued  soon  after  the  close  of 
the  Cono-ress. 


22 


TUBERCULOSIS  IN   THE   UisITED   STATES. 


Tuberculosis  has  been  more  or  less  steadily  decreasing  both  in  its 
absolute   and  in  its   relative  importance   as   a 


Decreasing      death 
from  tuberculosis. 
Table  1,  page  49. 


cause    of   death   for   many   years.     The    death 
rates  per  100,000  of  population  from  all  forms 

of  tuberculosis  declined,  as  follows,  in  the  registration  area  of  the 

United  States  from  1880  to  1907: 


Death 
rate. 


Per  cent 

of 
decrease. 


1S80  (census  year)  . . 
1890  (census  year)  . . 
1900  (calendar  year) 
1907  (calendar  year) 


326.2 
267.4 
201.2 
183.6 


18.0 
24.8 
8.7 


The  registration  area  of  1880  represented  only  a  comparatively 
small  portion  of  continental  United  States  and  was  largely  urban, 
so  that  the  decrease  from  1880  to  1890  may  be  partly  due  to  the 
addition  of  rural  population  in  the  registration  states  admitted  in 
1890.  Moreover,  comparisons  in  which  single  years  are  concerned 
are  not  so  satisfactory  as  those  based  upon  a  series  of  consecutive 
years,  as  in  the  following  table,  sho\^dng  the  decrease  in  the  death 
rates  from  all  forms  of  tuberculosis  in  Massachusetts  and  in  England 
and  Wales : 


1851-1860. 
1861-1870. 
1871-1880. 
1881-1890. 
1891-1900. 
1901-1906 1 


MASSACHUSETTS. 


Death  rate 
per  100,000 
of  popu- 
lation. 


469.9 
410.9 
391.5 
364.3 
283.2 
218.3 


Per  cent  of 
decrease 

from  pre- 
ceding 
decade. 


12.6 
4.7 
6.9 
22.3 
22.9 


ENGLAND  AND  WALES, 


Death  rate 
per  100,000 
of  popu- 
lation. 


348.7 
327.0 

287.8 
242.9 
200.9 
172.2 


Per  cent  of 
decrease 
from  pre- 
ceding 
decade. 


6.2 
12.0 
15.6 
17.3 
14.3 


1  Six-year  period. 

The  decline  has  been  especially  marked  in  Massachusetts  during 
,    ,  the  past  six  years,  the  per  cent  of  decrease  of 

Overstatement  of  tubercu-  ^.  .'  '  j.  i         i  i         n 

losis  in  early  statistics.  the  SIX  ycars  1901-1906  trom  the  decade  1891- 

Tabiei,  page49.  igQO  (22.9)  already  exceeding  that  shown  from 

1881-1890  to  1891-1900  (22.3).  The  decline  in  the  Enghsh  death 
rate  from  tuberculosis  has  been  remarkably  uniform.  Concerning 
this  Doctor  Tatham  remarks  that  "there  has  been  an  almost  steady 
and  not  a  slow  decline  in  the  aggregate  mortahty  from  tuberculosis, 
the  rate  in  the  last  year  being  less  than  half  that  in  the  earher  years, 
and,  further,  that  the  decHne  has  been  greater  in  females  than  in 


TUBERCULOSIS  IN   THE   UNITED   STATES.  23 

males,"  although  he  is  careful  to  note,  and  the  fact  should  be  taken 
into  consideration  in  comparing  all  extended  series  of  death  rates 
from  this  disease,  that  "with  respect  to  the  aggregate  mortality  from 
all  forms  of  tuberculosis,  although,  as  previously  mentioned,  the 
earlier  records  hardly  warrant  a  definite  conclusion,  it  is  at  least 
probable  that  in  the  fifties  and  sixties  of  last  century  mortality  was 
to  some  extent  overstated."  About  that  time  in  Massachusetts 
Hon.  John  G.  Palfrey,  secretary  of  state,  declared  in  the  third  annual 
registration  report  for  the  year  ending  May  1,  1844,  that  "consump- 
tion is  the  grand  receptacle  for  all  lingering  diseases,  of  whatever 
nature,  which  prove  fatal."  It  is  probable  that  the  present  tendency 
is  to  understatement,  rather  than  to  overstatement,  in  the  returns  of 
deaths  from  the  various  forms  of  tuberculosis. 

"Proportional  deaths"  showing  the  ratio  from  tuberculosis  per 
1,000  deaths  from  all  causes  have  some  degree  -proportional  deaths." 
of  usefulness,  because  they  indicate  the  relative  Tabid,  page 49. 
importance  of  this  cause  of  death  as  compared  with  others.  They 
do  not  show  the  incidence  of  mortality  upon  a  fixed  and  comparable 
basis,  and  the  figures  fluctuate  inversely  with  the  excessive  prevalence 
of  other  disease.  It  is  significant,  however,  that  in  Massachusetts, 
for  the  period  1851-1860,  over  a  quarter  of  the  deaths  at  all  ages 
(257.5  per  1,000)  were  from  tuberculosis,  while  now,  1901-1906,  less 
than  one-seventh  (131  per  1,000)  are  from  this  cause.  The  regis- 
tration area  gives  a  proportion  of  117.9  per  1,000  for  the  last  six 
years,  which  is  curiously  close  to  the  ratio  shown  by  the  returns  of 
the  Seventh  Census,  1850  (116.6  per  1,000),  although  no  safe  deduc- 
tions can  be  drawn  from  the  very  imperfect  older  statistics. 

In  order  to  appreciate  the  condition  of  the  United  States  as  com- 
pared with  other  parts  of  the  world  with  respect  ^^^^  ^^  f^^n^  comparable 
to  the  mortality  from  tuberculosis,  comparison  international  statistics  of 
of  the  death  rates  from  this  disease  may  be  made  ""^^^  ° 
on  the  basis  of  the  statistics  contained  in  the  international  tables 
printed  each  year  by  the  Registrar-General  of  England  and  Wales. 
Unfortunately  all  of  the  countries  do  not  tabulate  total  deaths  from 
tuberculosis,  so  that  it  is  necessary  to  restrict  the  comparison  to 
tuberculosis  of  the  lungs ;  and  there  may  be  some  considerable  element 
of  doubt  even  as  regards  the  deaths  thus  returned  as  a  result  of 
differences  in  statistical  methods  and  the  customs  followed  by  physi- 
cians in  the  various  countries  in  making  the  original  returns.  The 
paucity  of  fully  comparable  data  concerning  this,  the  most  important 
of  all  diseases,  shows  the  crying  need  for  a  universal  system  of  noso- 
logical classification,  and  the  desirability  that  the  medical  profession 
in  all  lands  be  induced  to  give  greater  attention  to  the  requirements 
incident  to  the  proper  reporting  of  causes  of  death. 


24  TUBERCULOSIS  IN   THE   UNITED  STATES. 

The  annual  average  death  rate  of  the  United  States   (169.9  per 
_    ,  r   r    •      100,000  of  population)  for  a  short  series  of  recent 

Death     rates     or     foreign  '  ^     ^  •      t 

countries.  jears  (1901  to  1905)  as  indicated  by  the  returns 

Table  2,  page  52.  froHi  the  registration  area,  places  this  country 

in  a  fairly  favorable  light  as  compared  with  others  for  which  data  are 
available.  Much  higher  rates  are  shown  for  Austria  (334.8)  and 
Servia  (279.7),  while  the  rates  for  Norway  (196.4),  Switzerland 
(188.6),  and  Germany  (185.8)  slightly  exceed  the  American  rate. 
Italy  (114.9),  Belgium  (118.2),  Netherlands  (133.4),  the  United 
Kingdom  (133.8),  Japan  (146.3),  and  Spain  (147.8)  fall  below  it. 
The  rate  for  England  and  Wales  in  particular  is  much  below  (121.5), 
but  Ireland,  with  an  abnormal  age  distribution  of  its  population, 
shows  a  higher  rate  (215.3).  The  extremely  low  mortality  of  the 
Australasian  states  is  very  remarkable,  ranging  from  111.6  for 
Victoria  to  only  63.3  for  Tasmania. 

Tuberculosis  may  seize  upon  any  organ  or  part  of  the  body.     It 
may  remain  localized  for  years,  as  in  a  kneejoint. 

How  tuberculosis  kills.  .,  ijiji  i  •  •  ,  i 

or  it  may  attack  the  entire  organism  at  once  and 
with  the  virulence  of  an  acute  infectious  disease,  as  in  acute  miliary 
tuberculosis.  It  is  not  yet  settled  in  statistical  practice  whether  the 
seat  of  the  initial  infection  should  be  reported,  if  known,  or  whether 
the  organ  upon  which  the  most  serious  inroads  are  made  should 
determine  the  classification  of  the  disease.  Probably  the  latter  plan 
is  preferable;  it  is  more  important  to  know  the  whole  number  of 
deaths  that  resulted  from  tuberculosis  of  the  lungs  than  to  attempt 
to  separate  the  comparatively  small  number  supposed  to  have 
resulted  from  primary  laryngeal  infection.  But  if  the  true  source 
of  infection  could  be  determined — whether  through  the  food  and  so 
on  indirectly  to  the  lungs,  or  directly  from  the  air — it  would  be  a 
matter  of  supreme  importance.  As  it  is,  the  mortality  statistics 
measure  only  the  results  and  the  primary  causes  remain  obscure. 

Among  the  multitude  of  forms  of  tuberculosis  recognized  by  the 
•  ,  .      ,         ,    ,  Nomenclature  of  Diseases  of  the  Royal  College 

Various  forms  of  tubercu-  .    .  ,i  /•    ii         • 

losis.  or    Physicians    or    London    are    the    rollowmg: 

Table  3,  page  52.  Tubcrculosis  of  adrcuals,  arteries,  bladder,  bones, 

brain,  bronchi,  conjunctiva,  fauces,  gums,  intestines,  kidneys,  joints, 
larynx,  liver,  lungs,  lymphatic  glands,  middle  ear,  mouth,  naso- 
pharynx, nerves,  nose,  pancreas,  pericardium,  peritoneum,  pharynx, 
pleura,  skin,  spleen,  stomach,  tongue,  and  of  other  organs  and  parts 
of  the  body.  It  is  needless  to  say  that  such  an  extended  list  would 
not  be  practicable  for  the  purposes  of  a  general  statistical  report,  and 
hence  all  statistical  classifications  attempt  to  reduce  the  most  im- 
portant forms  in  which  tuberculosis  causes  death  into  more  condensed 
lists.  For  example,  in  accordance  with  the  International  Classifica- 
tion of  Causes  of  Death,  the  following  forms  of  tuberculosis  were 


TUBERCULOSIS  IN   THE   UNITED   STATES. 


25 


compiled  for  the  registration  area  of  the  United  States  for  the  year 
1907: 


FORM  OF  TUBEECULOaiS. 


Number  of 
deaths. 


Tuberculosis  (all  forms) 

Tuberculosis  of  lungs 

Tuberculosis  of  larynx 

Tuberculous  meningitis 

Abdominal  tuberculosis 

Pott's  disease 

Tuberculous  abscess 

White  swelling 

Tuberculosis  of  otber  organs 
General  tuberculosis 


76,660 


66,374 

090 

4,0C2 

2,029 

594 

05 

209 

713 

1,254 


Nearly  nine-tenths  of  all  of  the  deaths  from  tuberculosis  are  due  to 
tuberculosis  of  the  lungs.  Some  of  the  forms 
given  are  of  very  minor  importance,  and  perhaps  ciass'St'onT  °^  ^f^'"'^'"' 
it  might  be  desirable  to  give  greater  detail  in 
regard  to  the  more  fatal  forms  of  the  disease.  Does  this  mode  of 
presentation  of  the  mortality  statistics  best  answer  the  purpose  of 
sanitarians  and  of  practical  clinicians  and  does  it  meet  the  demand 
for  complete  information  in  regard  to  all  features  of  this  disease  that 
will  surely  arise  from  the  present  concentration  of  attention  upon  it 
through  the  International  Congress  on  Tuberculosis?  If  not,  imme- 
diate steps  should  be  taken  to  suggest  the  necessary  changes  so  that 
they  may  be  incorporated  in  the  second  decennial  revision  of  the 
International  Classification  which  will  be  held  in  1909. 

For  the  purpose  of  comparison  with  the  above  statement  of  the 
methods  by  which  tuberculosis  kills,  we  may  submit  the  corresponding 
English  figures  for  1906  according  to  the  classification  used  by  the 
Registrar-General : 


FORM   OF  TUBERCULOSIS. 


Tuberculosis  (all  forms) . 


Pulmonary  tuberculosis  (tuberculous  phthisis) . 

Phthisis  (not  otherwise  deflned)  ' 

Tuberculous  meningitis 

Tuberculous  peritonitis 

Tabes  mesenienca  i 

Lupus 

Tubercle  of  other  organs 

General  tuberculosis 

Scrofula ' 


Number  of 
deaths. 


50,841 


18,384 
21,302 
6,104 
3,857 
1,238 
84 
1,809 
3, 954 
49 


1  Terma  in  italics  are  regarded  as  indefinite  and  unsatisfactory  by  the  Registrar-General. 

Sex  is  apparently  an  influential  factor  in  determining  differences 
in  mortality  from  tuberculosis.     For  the  states   influence  of  ses. 
of  the  registration  area  during  the  census  year   Table  4,  page  53. 
1900  the  death  rate  of  males  from  tuberculosis  of  the  lungs  was  188.4 
per  100,000  of  male  population,  while  the  corresponding  death  rate  of 


26  TUBERCULOSIS  IN   THE  UNITED  STATES. 

females  was  only  163.3.  The  mortality  of  males  exceeded  that  of 
females  from  this  disease  by  15.4  per  cent.  The  corresponding  rates 
for  1890  were,  for  males,  257.7  per  100,000  of  male  population;  for 
females,  240.4;  relative  male  mortality  in  excess  of  female  mortality 
from  "consumption,"  7.2  per  cent.  So  the  disproportionate  excess 
of  male  mortality  from  tuberculosis  of  the  lungs  more  than  doubled 
during  the  ten  years  that  elapsed  from  1890  to  1900.  In  Massachu- 
setts the  male  mortality  from  this  disease  began  to  exceed  the  female 
mortality  about  1894. 

A  similar  change  has  been  in  progress  in  England  and  Wales.  In 
the  earlier  years  of  registration  in  England  the  mortality  of  females 
from  "phthisis"  invariably  exceeded  that  of  males.  About  1856  the 
curve  representing  the  male  death  rate  rose  slightly  above  the  curve 
for  the  female  rate,  and  the  difference  has  increased  in  a  fairly  regular 
way  from  year  to  year  since  that  time.  During  the  decade  1861  to 
1870  the  death  rate  of  males  was  253.8  and  of  females  255.2,  while 
in  the  last  decade,  1891  to  1900,  the  rates  were  158.0  and  121.4, 
respectively. 

Certainly  such  changes  are  very  significant,  and  perhaps  are  due, 
to  some  extent,  to  a  progressive  tendency  among  women  to  Hve  more 
in  the  open  air  than  formerly.  The  "athletic  girl"  is  not  the  sort 
that  "goes  into  a  decHne"  in  the  interesting  way  common  to  fiction 
of  the  first  half  of  the  last  century,  but  there  must  be  an  additional 
reason,  first,  why  under  the  extremely  bad  hygienic  conditions  of  the 
old  days,  when  woman  was  considered  a  hothouse  plant  and  treated 
accordingly,  female  mortality  from  tuberculosis  was  not  vastly 
liigher,  not  merely  considerably  higher,  than  male  mortality;  and, 
second,  why  under  present  conditions  the  female  death  rate  is  now 
so  markedly  lower,  although  men  are  still,  on  the  whole,  more  com- 
monly engaged  in  outdoor  occupations  than  women. ^ 

Crowding  into  dense  city  quarters  means  increased  mortality  from 
City  and  country.  tuberculosis,  although  there  may  be  some  tend- 

Tabie4,  page53.  cncy  to  report  correctly  a  larger  proportion  of 

deaths  from  tuberculosis  in  the  city  than  in  the  country.  Following 
are  the  death  rates  from  tuberculosis  of  lungs  per  100,000  of  urban 
and  of  rural  population  in  the  registration  states  during  the  last  two 
decennial  census  years  and  the  last  year  contained  in  the  series  of 
annual  reports: 


Cities. 


Country. 


1906  (calendar  year) . 
1900  (census  year) . . . 
1890  (census  year) . . . 


181.5 
204.8 
293.5 


121.9 

134.1 
181.0 


^  Tuberculosis  affects  nutrition.  Women  are  perhaps  more  resistant  to  conditions 
affecting  nutrition  than  are  men.  In  India,  according  to  Sir  J.  A.  Baines,  "-women 
appear  to  succumb  to  famine  less  than  the  other  sex.-' 


TUBEECULOSIS   IN    THE   UNITED   STATES.  27 

The  rural  rate  in  1900  was  only  about  two-thirds  (07.1  ])cr  cent)  of 
the  urban  rate,  although  the  decrease  in  the  urban  rate  during  the 
period  of  sixteen  years  (.38.2  per  cent)  was  slightly  larger  than  the 
decrease  in  the  rural  rate  (32.7  per  cent).  States  with  a  large  pro- 
portion of  urban  population  will  tend  to  have  higher  death  rates 
from  tuberculosis  of  lungs  than  those  chiefly  rural  in  constitution; 
thus  in  1907  the  rates  for  New  York  (171.0),  New  Jersey  (170.0),  and 
Rhode  Island  (103.0)  exceeded  those  for  Indiana  (140.2),  Maine 
(134.3),  and  Michigan  (88.7).  Other  factors  must  be  considered, 
however,  in  addition  to  the  mere  density  of  population;  for  instance, 
the  younger  age  distributions  of  some  urban  populations  would  tend 
to  lower  mortalities. 

In  England  in  1900  the  urban  counties  showed  a  death  rate  from 
phthisis  of  149.3  per  100,000  of  population  while  the  corresponding 
rate  for  rural  counties  was  129.2,  the  excess  of  urban  mortality  being 
15.0  per  cent. 

One  of  the  influences  always  to  be  reckoned  with  in  the  analysis 
of  mortality  statistics  is  age  distribution  of  the      ^    , 

,         p     .,  ,  ,  ^,  Death  rates  at  certain  age 

deaths  and  or  the  people  among  whom  they  periods. 
occurred.  As  a  result  of  the  difficulties  attend-  ^^^^'^  ^'  p^s''  ^3- 
ant  upon  estimating  the  age  distribution  of  the  population  during 
postcensal  years  comparisons  are  most  conveniently  made  of  the 
death  rates  at  certain  ages  during  the  last  two  census  years,  1900  and 
1890.  The  aggregate  death  rate  at  all  ages  from  tuberculosis  of  the 
lungs  (pulmonary  ''consumption")  in  the  registration  states  declined 
from  249  per  100,000  of  population  in  1890  to  175.9  in  1900,  or  29.4 
per  cent;  for  the  thirty-year  period  of  life  from  15  to  44  years  of  age, 
it  fell  from  324.8  per  100,000  of  population  at  that  age  period  in  1890  to 
239.8  in  1900,  or  20.2  percent;  for  the  twenty-year  period  of  life  from 
45  to  04  years,  it  fell  from  310.2  to  208.4,  or  32.8 

1  p  ,  1  1  ,  Table  5,  page  55. 

per  cent ;  and  tor  the  older  ages,  05  years  and  over, 
it  fell  from  300.5  to  240.0,  or  31.0  per  cent.     Roughly  spealdng,  during 
the  ten  years  from  1890  to  1900  the  death  rate  from  "consumption" 
decreased  one-fourth  of  its  amount  for  young  and  middle-aged  adults  up 
to  44  years  of  age,  and  nearly  one-tliird  for  those  of  more  advanced  ages. 

The  highest  rate  shown  for  1900,  by  sex,  age,  and  locahty,  is  for 
males  aged  45  to  04  years  living  in  cities  (337.2  per  100,000  of  popula- 
tion), and  the  lowest  rate  is  for  females  of  the  same  age  period  living 
in  the  country  (141.0  per  100,000). 

The  different  forms  of  tuberculosis  vary  considerably  wath  refer- 
ence   to    the    periods    of    life    chiefly    afi"ected. 

.  •         ,    1       ^^  J       £    ±1  T       •^        £  Aee  distribution  of  deaths 

Approximately  28  per  cent  ot  the  deaths  from   ^^^^  various  forms  of  tuber- 
tuberculosis  of  the  lungs  occur  between  the  ages   cuiosis. 
of  25  to  34  years;  21  per  cent,  from  15  to  24      Table g,  page 55. 
years;  and  20  per  cent,  from  35  to  44  years.     Over  two-thirds  (67.4 


28  TUBERCULOSIS  IN   THE   UNITED   STATES. 

per  cent)  of  the  deaths  from  tuberculous  meningitis  are  those  of 
children  under  five  years  of  age. 

The  value  of  a  human  life  can  not  be  measured  in  dollars  and  cents. 
The  world  is  forever  poorer  on  account  of  the 

Economic  loss  from  tuber-   untimclv    death    of    Robcit    Louis    Stevenson, 

culosis.  "  ,  ' 

though  richer  for  the  record  of  his  brave  fight 
against  the  unrelenting  foe — tuberculosis — that  harried  him  to  the 
islands  of  the  great  "South  Sea "  he  loved,  and  slew  him  there.  What 
would  have  been  the  value  to  literature  of  a  few  more  years  of  this 
single  Kfe?  And  how  many  are  now  dying  from  tuberculosis  who, 
were  they  but  permitted  a  few  more  years  of  healthful  life,  would,  by 
their  works  of  genius,  add  immensely  to  the  treasures  of  humanity! 
Tuberculosis  kills  men  and  women  chiefly  in  the  most  active,  most 
productive  period  of  life,  when  their  work  is  worth  the  most  to  them- 
selves, to  their  families,  and  to  the  world. 

While  such  loss  can  not  be  stated  in  money,  for  it  transcends  all 

symbols  of  value,  we  may  consider  Avith  amaze- 

Estimates    of    pecuniary   ment  some  of  the  results  that  havc  been  obtained 

loss.  .  .  .  , 

by  conservative  writers  m  the  attempt  to  find 
some  clue  to  the  economic  injury  resulting  from  this  single  disease. 
In  an  article  on  ''The  Statistical  Laws  of  Tuberculosis,"^  ^Ir.  Freder- 
ick L.  Hoffman,  statistician  of  the  Prudential  Life  Insurance  Com- 
pany, says: 

Tubercxilosis  causes  annually  more  than  150,000  deatlis  in  the  United  States  at  the 
average  age  of  thirty-five  years.  At  this  age  the  normal  after-lifetime  is  about  thirty- 
two  years,  so  that  the  real  loss  of  life  covered,  measured  in  time,  is  represented  by 
4,800,000  years  per  annum.  If  we  assume  that  the  net  value  of  a  year  of  human  life 
after  age  thMy-five  is  at  least  $50,  the  real  loss  to  the  nation  resulting  from  the  disease 
(a  large  proportion  of  which  is  known  to  be  needless)  may  be  estimated  at  §240,000,000 
per  annum.  These  astounding  and  almost  incomprehensible  figures  are  far  from 
being  an  exaggeration,  but  let  us  assume  that  only  one-half  cf  this  mortality  is  pre- 
ventable, and  we  have  a  net  possible  saving  to  the  nation  of  $120,000,000  per  annum. 
This  estimate  does  not  take  into  account  the  social,  moral,  and  sentimental  value  of 
at  least  100,000  lives,  which,  under  different  conditions,  might  reasonably  hope  to 
continue  for  many  years.  The  mortality  from  tuberculosis  is,  therefore,  a  problem 
compared  with  which  all  other  social  problems  of  a  medical  character  sink  into  insig- 
nificance, and  it  is  safe  to  say  that  the  possible  prevention  of  a  large  portion  of  the 
mortality  from  this  disease  is  justly  desersdng  of  the  solicitude,  the  active  personal 
interest,  and  liberal  pecuniary  support  of  all  who  have  the  real  welfare  of  the  people 
of  this  nation  at  theu*  heart. 

Collier's  (July  25,  1908),  in  an  editorial  under  the  title  '"'Expressed 
in  Money,"  puts  it  higher:  ''Now  put  it  into  money,  this  same  saving 
to  the  race  through  intelligent  observation.  Hunter  has  estimated 
the  average  cost  of  preparing  a  man  for  usefulness  at  SI, 500.  *  *  * 
If  we  could  master  tuberculosis,  the  saving  in  money  to  the  United 

^Maryland  Medical  Journal,  Februarj',  1904. 


TUBERCULOSIS  IN   TUE   UNITED  STATES.  29 

States  would  be  $330,000,000  per  year.     Is  it  any  wonder,  then, 
that  the  best  physicians  are  heart  and  soul  in  the  study  of  prevention  ?" 
In  another  very  valuable  paper,^  from  which  several  paragrapha 
may  be  quoted  at  length,  Mr.  Hoffman  endeavors 

.  j^    1  !•   1      ii  '     •  -  p  •    1     Economic  value  of  life. 

to  establish  the  approximate  measure  of  social 
and  economic  value  of  life : 

Life  period  of  industrial  activity. — The  period  of  industrial  activity  of  wage-earners 
generally,  but  chiefly  of  men  employed  in  mechanical  and  manufacturing  industries, 
it  may  be  assumed,  should  properly  commence  with  the  age  of  fifteen  and  terminate 
at  sixty-five.  This  gives  fifty  years  of  labor  and  life,  during  which,  as  the  result  of 
individual  effort,  primarily,  of  course,  for  self-maintenance  and  the  support  of  others, 
some  net  addition  is  annually  made  to  the  accumulated  wealth  of  the  nation.  The 
large  variety  of  employments,  which  is  so  characteristic  of  modern  nations,  and  the 
increasing  subdivision  of  labor  and  the  development  of  special  ability,  precludes 
more  than  an  approximate  estimate  of  what  normally  constitutes  the  economic  gain 
to  society  during  the  period  of  industrial  activity  of  a  wage-earner. 

Economic  and  social  value  of  life. — The  usual  method  has  been  to  confuse  cause  and 
effect  and  to  estimate  the  present  value  of  a  workingman's  life  merely  upon  the  basis 
of  his  future  earnings  after  deducting  the  cost  of  future  maintenance.  This  method, 
however,  does  not  establish  the  economic  value  of  men  to  society,  but  rather  the  social 
value  of  a  man  to  himself  and  his  family  or  survivors.  The  economic  gain  to  society, 
as  I  view  it,  is  rather  the  value  of  the  product  over  and  above  wages,  cost  of  supervision, 
cost  of  material,  and  miscellaneous  expenses,  necessarily  incurred  to  carry  on  any 
particular  process  of  manufacture  or  industry.  A  fairly  accurate  basis  for  an  esti- 
mate of  this  kind  is  furnished  by  the  census  returns  of  our  manufacturing  industries, 
which  give  employment  to  some  seven  million  persons.  While  any  calculation  of  this 
character  must  necessarily  be  merely  approximate,  it,  however,  will  prove  useful 
for  the  present  purpose,  to  establish  the  principle  that  there  is  an  economic  value 
inherent  in  every  year  of  a  workman's  life,  and  that  every  gain  in  human  longevity 
above  the  age  of  fifteen  and  below  the  age  of  sixty-five  represents  a  corresponding  gain 
to  the  nation  at  large  and  a  distinct  contribution  to  the  accumulated  wealth  and 
capital  of  the  nation. 

Variations  in  industrial  efficiency. — It  is  probably  safe  to  assume  that  the  net  gain  to 
society  is  at  least  equivalent  to  about  three  hundred  dollars  per  annum  in  the  case  of 
male  wage-earners  employed  in  American  manufactiu'ing  and  mechanical  industries. 
The  return  is  higher,  among  others,  in  the  manufacture  of  food  and  kindred  products, 
also  in  the  manufacture  of  metal  ware,  paper,  printing,  and  chemicals.  It  is  lower, 
among  others,  in  the  manufacture  of  textiles,  leather,  clay,  glass,  stoneware,  and 
tobacco.  Making  allowance  also  for  the  lower  wages  of  women  and  the  relatively 
small  earnings  of  children  below  the  age  of  fifteen  in  industries,  which  are  included 
in  the  census  returns,  the  average  of  three  hundred  dollars,  assumed  for  the  present 
purpose,  would  appear  to  fairly  correspond  to  the  facts  of  actual  experience.  Of 
course,  the  gain  is  less  at  the  younger  ages  and  probably  remains  fairly  the  same  or 
level  during  the  ages  of  thirty  to  fifty,  when  the  normal  physical  strength  is  enhanced 
by  practical  trade  education  and  experience.  After  the  age  of  fifty  a  natural  decline 
in  physical  strength  and  possibly  brain  weariness  gradually  decreases  the  industrial 
efficiency,  which  in  the  case  of  wage-earners  may  be  held  to  come  practically  to  an  end 
by  about  the  age  of  sixty-five  to  seventy.  There  are,  of  course,  always  some  excep- 
tions in  every  trade  and  industry,  where  men  continue  to  work,  sound  in  body  and 
mind,  to  the  close  of  a  long  life. 

'  "Physical  and  Medical  Aspects  of  Labor  and  Industry,"  Annals  of  the  American 
Academy  of  Political  and  Social  Science,  May,  190G. 


30 


TUBERCULOSIS  IN   THE   UNITED   STATES. 


Economic  loss  by  premature  mortality. — Upon  the  assumption  of  an  average  annual 
net  gain  to  society  of  three  hundred  dollars  as  the  result  of  individual  labor  applied  to 
American  industry  under  normal  conditions,  the  degree  of  variation  in  value  may  be 
placed  between  the  minimum  of  seventy-five  dollars  at  the  age  of  fifteen  and  a  maxi- 
mum of  four  hundred  dollars  at  the  age  of  thirty-two.  The  value  is  then  assumed  to 
remain  about  the  same,  or  level,  until  the  age  of  forty-eight,  when  industrial  efficiency 
gradually  declines  as  the  result  of  decreasing  strength  and  mental  aptitude  and  inclina- 
tion. The  minimum  value  at  the  end  of  industrial  life  is  assumed  to  be  one  hundred 
and  seventy  dollars.  By  means  of  this  estimate,  which,  of  course,  is  purely  theoretical, 
in  that  there  are  no  wage  statistics  by  ages,  or  useful  observations  of  employers  of  labor 
respecting  the  industrial  efficiency  of  employees  at  different  periods  of  life,  it  is  pos- 
sible to  calculate  with  approximate  accuracy  the  economic  loss  due  to  premature  death 
or  impaired  physical  efficiency  as  the  result  of  illness.  If,  upon  the  basis  of  an  average 
net  gain  to  society  of  three  hundred  dollars  per  annum,  the  fifty  active  years  of  a  work- 
ingman's  life  represent  a  total  of  fifteen  thousand  dollars,  then  if  death  should  occur  at 
the  age  of  twenty-five,  the  economic  loss  to  society  would  be  thirteen  thousand  six 
hundred  and  ninety-five  dollars;  if  at  the  age  of  thirty-five  it  would  be  ten  thousand 
three  hundred  and  ninety-five  dollars;  if  at  the  age  of  fifty,  four  thousand  four  hundred 
and  five  dollars;  and,  finally,  at  the  age  of  sixty,  the  loss  would  still  l^e  one  thousand 
and  ninety  dollars.  Of  course,  the  values  would  vary  considerably  in  different 
employments,  but  the  broad  principle  is  fairly  well  illustrated  and  with  approximate 
accuracy  in  this  calculation. 

Now,  the  approximate  average  age  at  death  of  the  persons  dying 
from  tuberculosis  of  the  lungs  (pulmonary  '' con- 
sumption") in  the  United  States  is  practically 
about  thirty-five  years,  a  figure  which  has  been  curiously  stationary 
for  each  year  for  which  the  statistics  are  available  since  1860,  although 
the  average  age  at  death  from  all  causes  has  increased  from  22.7  years 
in  1860  to  38.1  years  in  1907. 


Approxi- 
mate aver- 1  Approxi- 
age  age  at  '  mate  aver- 
deatli  from  I  age  age  at 
tuberculo-  jdeath  from 
sis  of  j  all  causes, 
lungs. 


United  States: 

Census  year  1860 1 . 
Census  year  1870.. 
Census  year  1880.. 

Registration  area: 
Census  year  1890. . 
Census  year  1900 . . 

Calendar  year  1900 
Calendar  year  1901 
Calendar  year  1902 
Calendar  year  1903 
Calendar  year  1904 
Calendar  year  1905 
Calendar  year  1906 
Calendar  year  1907 


349 
36,7 
35.^ 


35.3 
35.3 

35.3 
35.5 
35.5 
35.3 
35.1 
35.3 
35.5 
35.9 


22.7 
25.2 
36.9 


31.1 
35.2 

35.1 
37.0 
36.3 
37.2 
37.5 
37.5 
36.8 
3&1 


i 

j   PER  CENT 

OF  DEATHS 

UNDER   5 

l-EAES    OF 

AGE. 

Tuberculo- 

sis of 

All  causes. 

!      lungs. 

! 

7.9 

42.7 

6.4 

40.2 

5.2 

37.9 

3.9 

34.6 

3.6 

30.0 

a5 

30.4 

a2 

27.3 

3.0 

28.2 

ai 

26.7 

2.9 

26.5 

2.8 

27.0 

3.1 

28.4 

ai 

26.7 

Approxi- 
mate medi- 
an age  at 
death  from 
tuberculo- 
sis of 
limgs. 


30.9 
32.7 
31.2 


31.6 
32.5 

31.8 
32.0 
32.1 
32.0 
31.8 
32.1 
32.3 
32.8 


1  Estimate  based  on  ten-year  periods  from  30  years  to  90  years. 

As  the  average  age  at  death  is  a  ver}^  doubtful  ratio,  depending 
chiefly  upon  the  average  age  of  the  population  or  special  class  sus- 
ceptible to  an  individual  disease,  the  figures  given  in  the  above  table 


TUBERCULOSIS  IN   THE   UNITED   STATES.  31 

must  be  cautiously  used;  subsidiary  columns  are  given  for  the  ])er- 
centages  of  deaths  under  five  years  of  age  as  affecting  pulmonary 
tuberculosis  and  deaths  from  all  causes,  and  also  the  approximate 
median  age  at  death  from  tuberculosis  of  the  lungs,  which  is  the  age 
for  which  one-half  of  the  persons  dpng  from  this  disease  are  older  and 
one-half  younger.  The  latter  ratio  is  somewhat  lower  than  the 
average  age  at  death,  and  likewise  shows  only  a  slight  variation 
during  the  series  of  years.  As  age  at  last  birthday  forms  the  basis 
of  the  compilation,  one-half  year  may  be  added  to  show  the  true 
approximate  average  or  median  age  at  death. 

Of  the  42,734  deaths  of  males  from  all  forms  of  tuberculosis  in  the 
registration  area  of  the  United  States  during      y   .,         ,     ,      ,   . 

°  '^         Incidence    or    tuberculosis 

1907,  12,035,  or  28.2  per  cent,  were  at  the  ages  upon  the  most  productive 
15  to  29  years,  both  mclusive;  14,423,  or  33.8  ^s"' 
per  cent,  at  the  ages  30  to  44  years;  and  9,679,  or  22.6  per  cent,  at 
the  ages  45  to  64  years.  During  the  younger  and  probably  most 
efficient  period  of  industrial  activity,  from  15  to  44  years,  occurred 
26,458,  or  61.9  per  cent  (nearly  two-thirds),  of  all  of  the  male  deaths 
from  tuberculosis.  And  for  the  entire  "fifty  years  of  labor  and  life," 
as  expressed  by  Mr.  Hoffman,  there  were  36,137  deaths  of  men,  or  84.6 
per  cent  of  the  total  male  deaths  from  all  forms  of  tuberculosis. 
So  at  least  four-fifths  of  all  of  the  deaths  of  males  from  this  disease 
mean  direct  loss  of  earning  power  in  men  who  are  productively 
employed. 

If  we  take  the  26,458  deaths  of  men  aged  from  15  to  44  years  in  the 
registration  area,  1907,  and  assume  that  their  average  age  at  death 
was  about  35  years  or  somewhat  less  (from  tuberculosis  of  lungs  it 
was  31  years),  then  consider  the  economic  loss  to  society,  according 
to  Mr.  Hoffman's  computation,  to  be  $10,395  at  the  age  of  35,  we  shall 
have  a  total  economic  loss,  in  the  registration  area  alone,  from  the 
deaths  of  this  limited  most  productive  age  class  of  males  only,  dur- 
ing a  single  year  of  experience  amounting  to  $275,030,910.  The 
registration  area  includes  less  than  one-half  of  the  population  of  the 
United  States,  It  is  not  profitable  to  press  such  estimates  too 
closely,  but  it  is  easy  to  see  that  there  is  a  tremendous  waste  dis- 
tributed throughout  society,  and  pressing  with  the  greatest  cruelty 
upon  the  weakest  dependent  members  of  the  families  from  which 
tuberculosis  has  removed  the  means  of  support. 

For  a  thorough  analysis  of  the  effects  of  tuberculosis  in  limiting 
the  productive  capacity  of  man  a  life  table  must 

1  1  ix-ij^i'  T-»i«  TXT  Westereaard's     life    table, 

be  employed.     Jbor  this  purpose  rrofessor  Wes-   excluding  tuberculosis. 
tergaard^  has  computed  the  effect  upon  the  life 

^"The  Horoscope  of  the  Population  of  the  Twentieth  Century,"  Bulletin  de 
rinstitut  Internationale  de  Statistique,  1907,  xvii,  103. 


32 


TUBERCULOSIS   IIST    THE    UNITED    STATES. 


table  of  England,  1881-1891,  upon  the  assumption  that  tuberculous 
diseases  can  be  eliminated: 


Oy^ars. 
5  years. 
15  years 
25  years 
35  years 
45  years 
55  years 
65  years 
75  years 
85  years 
95  years 


ENGLISH  LIFE- 
TABLE,  1881-1891. 


Males. 


10,000 
7,515 
7,262 
6,938 
6,396 
5,644 
4,630 
3,225 
1,539 
299 


Females. 


10,000 
7,832 
7,591 
7,248 
6,710 
6,040 
5,164 
3,855 
2,042 
481 
21 


TTJBEECTTLOTTS  DIS- 
EASES ELIMI- 
NATED. 


Males. 


10,000 
7,629 
7,410 
7,209 
6,873 
6,304 
5,381 
3,889 
1,911 
378 
11 


Females. 


10,000 
7,928 
7,730 
7,535 
7,195 
6,668 
5,837 
4,439  i 
2,387  I 
568  ] 
27 


GAIN  FEOM  ELIMI- 
NATION OF  TU- 
BEECULOTJS  DIS- 
EASES. 


Males.     Females. 


114 

% 

148 

139 

271 

287 

477 

485 

660 

628 

751 

673 

664 

584 

372 

345 

79 

87 

3 

6 

Out  of  10,000  newborn  children  of  each  sex,  6,873  males  and  7,195 
females  would  reach  the  age  of  35  provided  tuberculous  diseases 
could  be  done  away  with,  as  against  6,396  males  and  6,710  females 
who  would  reach  that  age  under  present  conditions.  This  represents 
a  gain  to  the  community  of  477  males  and  485  females  at  this  single 
age  period.  The  probabihty  that  a  man  aged  25  would  reach  the 
age  of  35  under  the  conditions  of  the  Enghsh  life-table  employed 
is  92.1  per  cent;  with  tuberculosis  eliminated  it  would  be  95.3  per 
cent. 

In  the  course  of  human  life  from  infancy  to  old  age  each  period 
has  its  peculiar  perils.     All  over  the  world  the 

Relative  importance  of  tu-     i      ,  .  -,     .  .  i  p 

bercuiosis  and  other  dis-  babics  are  dying  lu  unneccssarj^  numbers  from 
^^ses.  filth,    foul    milk,    and    the    various    causes    of 

e  /,  page  o .  diarrhea  and  enteritis.     After  the  ordeal  of  early 

infancy,  the  gantlet  of  measles,  whooping  cough,  and  scarlet  fever  must 
be  run.  Then  come  the  comparatively  immune  days  of  early  youth, 
when  the  death  rate  falls  to  its  lowest  ebb  during  the  entire  period  of 
existence,  and  then  the  tide  of  death  begins  to  rise,  with  the  Bacillus 
tuberculosis  as  the  chief  causative  agent,  until,  with  advancing  years, 
the  degenerative  changes,  due  chiefly  to  improper  or  unwise  living, 
become  of  chief  importance,  and  even  tuberculosis  must  play  a 
secondary  role.  In  the  practical  everyday  conflict  with  disease  that 
is  being  waged  by  sanitary  authorities,  it  is  of  importance  to  know 
just  where  to  direct  the  attack — what  causes  of  sickness  and  death 
are  of  the  greatest  relative  importance,  both  at  all  ages  and  at  the 
various  special  periods  of  life. 

For  all  ages,  according  to  the  mortality  statistics  of  the  registration 

All  ages.  area  of  the  United  States  during  the  year  1907, 

(4),  page  56.  11.2  per  cent  of  the  deaths  from  all  causes  were 

from  some  form  of  tuberculosis.     Tuberculosis  of  the  lunss  alone  was 


TUBERCULOSIS   IN   THE   UNITED   STATES.  33 

responsible  for  9.7  per  cent  of  the  total  deaths  of  the  year.  Pneu- 
monia, including  bronchopneumonia,  came  next  to  tuberculosis  as  a 
cause  of  death,  with  a  percentage  of  9.8,  then  heart  disease  (8.6  per 
cent),  violence  (7.6  per  cent),  and  diarrhea  and  enteritis  (7.1  per  cent). 

For  infants  and  children  under  15  years  of  age,  the  percentage  of 
deaths  from  all  forms  of  tuberculosis  {according  infants  and  children. 
to  the  returns)  is  low  (4  per  cent).  But  many  (5),  page  so. 
of  the  deaths  from  meningitis  (unqualified),  "convulsions,"  and  from 
diarrhea  and  enteritis  are  probably  due  to  tuberculous  infection. 
The  story  of  the  dealings  of  tuberculosis  with  infancy  and  childhood 
is  not  yet  told  in  the  statistics,  nor  will  it  be  until  physicians  are 
much  more  careful  in  their  certificates  of  cause  of  death,  and,  indeed, 
until  science  has  rendered  it  less  difficult  to  obtain  precise  information 
in  many  instances. 

For  youth  and  early  manhood  and  womanhood  (15  to  29  years 
of  age),  nearly  a  third  (33.2  per  cent)  of  all  of      v    .u     j      .        u    j 

'^    '  >  'J  ^  ■[  _        '  Youth  and  early  manhood 

the  deaths  are  due  to  tuberculosis  in  some  of  its  and  womanhood. 
forms.  For  females  the  proportion  is  even  (c^), pages?. 
higher  (38.3  per  cent).  The  mortality  from  no  other  cause  ap- 
proaches that  from  this  disease,  the  nearest  being  violence  (16.8  per 
cent),  typhoid  fever  (7.4  per  cent),  pneumonia  (6.7  per  cent),  and 
heart  disease  (4.3  per  cent).  Here  is  where  the  most  immedi- 
ately beneficial  results  of  the  active  campaign  against  tubercidosis 
should  first  be  perceived. 

For  mature  manhood  and  womanhood  (30  to  44  years)  over  a 
quarter  (25.6  per  cent)  of  all  of  the  deaths  are  j^^^^^^  ^^^^^^  ^^^ 
from  tuberculosis,  but  the  relative  importance  womanhood. 
of  the  disease  as  a  cause  of  death  is  less  because  (-D).  page  57. 
of  the  increased  fatality  of  other  diseases.  Violence  (13.1  per  cent), 
pneumonia  (8.8  per  cent),  Bright's  disease  (7.5  per  cent),  and  heart 
disease  (7.1  per  cent)  are  the  next  most  important  causes,  and  cancer 
(4.5  per  cent)  now  makes  its  appearance  as  a  considerable  cause 
of  death. 

The  period  from  45  to  59  years  is  hard  to  designate;  perhaps  we 
may  call  it  the  harvest  time  of  life,  as  it  should   The  harvest  time  of  life, 
be,  after  the  exertions  of  mature  manhood  and    (S),page58. 
womanhood  and  before  the  shadows  of  advancing  years  become  too 
pronounced.     Here  tuberculosis  ceases  to  be  the  most  important 
cause  of  death;  its  proportion  of  the  total  (12.1  per  cent)  is  reduced 
to  one-half  of  that  of  the  preceding  period.     This  is  because  the 
degenerative  diseases  begin  at  these  ages  rapidly  to  increase  in  their 
efi'ect  upon  the  death  rate.     Violence  declines  (8.5  per  cent)  because 
the  days  of  most  active  labor  are  over,  but  heart  disease  (12.5  per 
cent)  now  exceeds  tuberculosis  and  becomes  the  leading  cause  of 
death;  nephritis  and  Bright's  disease  (11  per  cent)  is  close  behind; 
and  cancer  (10.5  per  cent)  is  almost  equally  important. 
53046—08 3 


34  TUBEECXJLOSIS  IN   THE   UNITED   STATES. 

Advancing  age  yields  fewer  deaths  in  proportion  from  tuberculosis 
Advancing  age.  (4-6  per  Cent),  wliile  heart  disease  (17.4  per  cent), 

(i^),pageo8.  nephritis  and  Bright's  disease  (11.5  per  cent), 

apoplexy  (10.5  per  cent),  and  other  organic  affections  absorb  the 
lion's  share.     The  death  rate  from  tuberculosis  is  also  diminishing, 
and  in  the  final  period  of  life,  from  75  years  of  age  upwards,  the 
proportion  of   deaths  from  tuberculosis  is  less 
than  in  any  of  the  preceding  age  periods. 
The  relative  frequency  of  deaths  from  tuberculosis  as  compared 
with  other  causes  varies  among  the  different 
deaths  from  tuberculosis  by   statcs    of    the    registration    area.     The    deaths 
states.  necessarily  include  those  of  nonresidents,  many 

of  whom  are  invalids  who  have  resorted  to  the 
states  in  which  their  deaths  occurred  in  search  of  health,  and  hence  the 
relative  proportion  of  deaths  from  tuberculosis  or  even  the  absolute 
death  rate  does  not  gage  the  natural  healthfulness  of  the  state  with  re- 
spect to  tuberculosis.  In  California  no  less  than  15  per  cent  of  all 
deaths  that  occurred  during  the  year  1907  were  from  tuberculosis;  in 
Colorado  even  more,  16.4  per  cent;  while  ^Michigan  showed  only  7.4 
per  cent,  Vermont  8. 1  per  cent,  and  New  Hampshire  7.6  per  cent.  But 
consumptives  go  from  ]\Iichigan,  Vermont,  and  New  Hampshire  to 
California  and  Colorado,  and  there  is  no  systematic  plan  yet  accepted 
whereby  their  deaths,  should  they  occur  in  the  latter  states,  may 
be  charged  back  to  the  states  in  which  the  disease  originated.  For 
some  valuable  data  on  this  point  reference  may  be  made  to  the 
recent  registration  reports  published  by  the  state  board  of  health 
of  California.  The  time  mil  undoubtedly  come,  -with,  the  more 
general  extension  of  the  registration  area,  when  it  will  be  possible 
to  establish  equitable  rules  for  this  purpose. 

The  influence  of  color  has  aheady  been  referred  to,  although  it  is 
Color.  difficult  to  dissociate  the  influences  of  race  and 

Table  9,  page  60.  Conditions  of  hfe  as  related  to  the  production  of  an 

excessive  mortahty  from  tuberculosis.  According  to  the  returns  from 
the  registration  area  of  1900,  the  colored  death  rate  from  pulmonary 
tuberculosis  (490.6  per  100,000  of  colored  population)  exceeded  the 
white  death  rate  (173.5)  by  182  per  cent.  Death  rates  of  the  colored 
included  chiefly  the  residents  of  the  nonregistration  cities  of  the 
South.  Until  the  admission  of  Maryland  in  1906  as  a  registration 
state,  there  existed  no  appreciable  amount  of  returns  from  rural 
colored  population,  so  that  all  of  the  comparative  death  rates  of 
white  and  colored  must  be  taken  with  much  caution. 

According  to  the  mortahty  statistics  of  the  census  3^ear  1900,  the 

Conjugal  condition.  death  rate  of  unmarried  males  aged  15  years  or 

Table  10,  page  60.  ovcr  from  tubcTculosis  of  the  lungs  (309.8  per 

100,000  persons  of  this  class  in  the  population)  was  considerably 


TUBERCULOSIS   IN   THE   UNITED   STATES.  35 

higher  than  that  of  unmarried  females  of  the  same  ages  (225.2),  The 
death  rates  of  married  males  and  married  females  were  practically  tho 
same  (215.5  and  216.4,  respectively),  but  ^vith  the  widowed  again, 
the  male  rate  (465)  considerably  exceeded  that  of  the  female  (2.35.1). 
For  the  three  age  periods  shown,  the  highest  death  rate  from  pulmo- 
nary tuberculosis  was  that  of  widowers  aged  from  15  to  44  years  (667), 
while  the  lowest  rate  was  that  of  married  women  aged  from  45  to  64 
years. 

The  incidence  of  tuberculosis  of  lungs  (pulmonary  "consumption") 
as  compared  with  other  diseases  upon  the  gen-  Relative  prevalence  of  tu- 
eral  classes  of  occupations  may  serve  to  draw  bercuios's  by  classes  of  occu- 
some  broad  lines  of  distinction,  but  the  groups  Table  ii,  page  oo. 
of  occupations  are  hardly  sufficiently  definite  to  yield  results  of  much 
value.  Moreover,  the  fact  must  be  considered  that  they  difler  con- 
siderably in  age  distribution,  and  this  is  a  very  important  factor  of 
the  death  rate.  Tuberculosis  of  lungs  caused  376.8  deaths  per 
100,000  of  the  laboring  and  servant  class  in  1900,  being  the  maximum 
rate  shown  for  any  class  of  occupations,  and  the  lowest  rate  for  tuber- 
culosis of  lungs,  147.2  per  100,000,  was  among  those  engaged  in  agri- 
culture, transportation,  and  other  outdoor  employment. 

More  specific,  and  hence  generally  more  valuable,  information  is 
obtainable  from  the  examination  of  the  death  ^^^^^  ^^  tuberculosis  for 
rates  from  tuberculosis  of  certain  listed  occupa-  specified  occupations. 
tions  of  each  sex,  the  statistics  being  hmited  to  "^^^'^  ^^'  p*^®  ^^• 
persons  over  10  years  of  age  employed  in  gainful  occupations  in  the 
registration  states  during  the  census  year  1900.  Here  again  the 
difference  in  age  constitution  of  the  persons  employed  must  be  con- 
sidered, and  data  upon  this  point  are  available  for  the  most  important 
occupations  shown  in  the  volume  on  Vital  Statistics,  Part  I,  of  the 
Twelfth  Census  reports,  to  which  reference  should  be  made. 

The  highest  death  rate  from  tuberculosis  of  the  lungs  per  100,000 
of  persons  of  specified  occupation  in  the  popu- 
lation in  1900  was  that  of  marble  and  stone  cut-  ^^  tuberculoses.  ™°^'  ^"  ''"^ 
ters  (540.5),  followed  by  that  of  cigarmakers 
and  tobacco  workers  (476.9),  compositors,  printers,  and  pressmen 
(435.9),  servants  (430.3),  and  bookkeepers,  clerks,  and  copyists  (398). 
Laborers  (not  agricultural)  showed  a  high  rate  (370.7),  but  farmers, 
planters,  and  farm  laborers  had  one  of  the  lowest  rates  for  males  in  the 
list  (111.7).  Occupational  mortahty  is  one  of  the  most  important 
features  in  vital  statistics,  but  it  is  subject  to  many  practical  diffi- 
culties in  the  collection  of  the  data,  which  come  from  two  sources, 
namely,  the  enumerators'  returns  of  population  and  the  registration 
returns  of  deaths.  Unless  the  statement  of  occupation  is  identical  for 
the  population  and  for  the  deaths,  there  is  much  risk  of  overstatement 
or  understatement  of  the  mortahty  from  a  given  occupation.     Hence 


36  TUBERCULOSIS   IN   THE   UNITED   STATES. 

special  caution  is  recommended  in  employing  comparative  occupa- 
tional rates  of  mortality. 

The  death  rates  due  to  all  forms  of  tuberculosis  may  be  studied  for 

Death  rates  from  tubercu-  the  jesLTs  for  which  the  aimual  reports  on  mor- 
losis  (aU  forms)  by  states  and  taKty  statistics  havc  bccu  Compiled,  but  it 
Table  13,  page  66.  should  be  remembered  that  a  considerable  addi- 

tion was  made  to  the  registration  area  in  1906,  and  that  in  con- 
sequence thereof  some  of  the  relations  between  its  main  subdivisions 
are  disturbed.  Comparisons  between  the  years  1907  and  1906  need 
no  correction,  nor  are  corrections  required  in  examining  the  rates  for 
the  individual  states  and  cities. 

The  total  death  rate  of  the  registration  area  from  all  forms  of  tuber- 
culosis in  1907  (183.6  per  100,000  of  population)  was  sHghtly  less 
than  in  1906  (184.2),  and  all  of  the  main  subdivisions  showed  a 
decrease  except  the  rural  part  of  registration  states,  which  increased 
from  140.4  to  142.5. 

Six  of  the  fifteen  registration  states  showed  increased  mortahty 
from  tuberculosis,  but  the  changes  are  well  within  the  hmits  of  the 
ordinary  annual  fluctuations.  The  highest  death  rates,  by  states,  in 
1907,  were  those  of  Colorado  (289.4)  and  California  (278.9),  both 
favorite  resorts  for  the  tuberculous;  Rhode  Island  (200.9),  very 
densely  populated  and  largely  urban;  and  Maryland  (200.2),  with  its 
large  colored  population.  The  lowest  rates  were  in  Mchigan  (103.5), 
South  Dakota  (105.1),  New  Hampshire  (130.5),  and  Vermont  (131.2). 

For  San  Francisco  recent  rates  can  not  be  given  because  of  the 
difficulty  in  estimating  population  since  the  earthquake  of  1906.  The 
immensely  high  mortaHty  of  Denver  (486.6)  is  due  to  the  inclusion  of 
the  deaths  of  nonresident  tuberculous  invahds,  as  is  also  that  of  the 
Bronx  borough  (512.6),  which  includes  hospitals  receiving  patients 
from  Manhattan  and  other  boroughs  of  Greater  New  York.  For  a 
fuller  study  of  the  variations  of  mortaHty  in  the  individual  cities 
reference  should  be  made  to  the  detailed  data  in  the  annual  reports. 

11. — The  Work  of  the  Bureau  of  the  Census  in  Vital 

Statistics. 

In  order  to  obtain  a  correct  idea  of  the  relation  of  the  Bureau  of 

the  Census  to  the  registration  of  vital  statistics, 

Relation  of  the  Census  to    ^  ^^  incidcntaUy  to  cast  somc  Hght  upon  the 

registration.  "^  o  jt 

vaHdity  of  the  results  obtained  and  to  suggest 
means  of  improvement,  the  mechanism  of  the  registration  and  com- 
pilation of  vital  statistics  must  be  studied. 

The  working  force  of  the  Bureau  of  the  Census,  formerly,  and  still 
informally,  known  as  the  "Census  Office,"  is  divided  into  four  princi- 


TUBERCULOSIS  I^:    THE   UNITED   STATES.  37 

pal  "divisions"  in  accordance  with  the  chief  Hnes  of  statistical 
inquiry.     These  are : 

(1)  Division  of  Population. 

(2)  Division  of  Manufactures. 

(3)  Division  of  Agriculture. 

(4)  Division  of  Vital  Statistics. 

Before  the  organization  of  the  permanent  Census  Office  in  1002,  the 
work  of  the  Census  was  necessarily  confined  to  the  compilation  of 
data  collected  by  or  during  the  decennial  enumerations.  Wliile  the 
material  necessary  for  statistics  of  population,  manufactures,  and 
agriculture,  can  be  so  obtained,  it  was  recognized  at  a  very  early  date 
that  vital  statistics  could  not  be  collected  satisfactorily  by  enumera- 
tion, and,  beginning  with  the  Tenth  Census,  1880,  an  effort  was  made 
to  obtain  better  returns  of  deaths  by  substituting  the  results  of  imme- 
diate registration,  under  laws  requiring  burial  permits,  as  conducted 
by  certain  states  and  cities.  The  registration  area  thus  instituted 
has  increased  until  at  present  it  comprises  nearly  one-half  (48.8  per 
cent  in  1907)  of  the  total  population  of  continental  United  States; 
and  with  the  effective  enforcement  of  new  laws  already  in  operation 
or  Hkely  to  be  passed  in  1909,  it  is  possible  that  it  will  embrace  nearly 
two-thirds  of  the  entire  population  at  the  date  of  the  Thirteenth 
Census,  1910. 

Taking  a  tyjiical  state  of  the  registration  area  as  an  example,  the 
following  processes  would  occur  in  the  registration  and  compilation 
of  a  death : 

1.  The  undertaker  or,  in  the  absence  of  an  undertaker,  the  person 
in  charge  of  the  interment,  removal,  or  other 

disposition  of  the  body,  takes  a  blank  certificate     .  ^"'^  °^^  undertaker,  reia- 

^  ''  '  .  .  tive,  and  attending  physician. 

of  death  provided  him  by  the  state  registration 

office,  (1)  has  it  filled  out  with  the  name,  sex,  age,  color,  conjugal  con- 
dition, occupation,  and  other  personal  particulars  concerning  the 
decedent  and  signed  by  a  relative,  friend,  or  other  person  acquainted 
with  the  facts;  then  (2)  presents  the  certificate  thus  far  filled  out  to 
the  attending  physician,  or  coroner  in  certain  cases  of  violent  death, 
who  fills  out  the  medical  certificate  of  cause  of  death;  and  finally  (3) 
delivers  it  to  the  local  registrar  of  death  hefore  the  interment,  removal, 
or  other  disposition  of  the  body. 

2.  The  local  registrar  receives  and  examines  the  certificate  dehvered 
to  him  by  the  undertaker,  and  if  it  is  properly    _       , ,     ,     . 

Z'  .  1         .    1  •  1       I^ufy  °^  ^°'^^  registrar. 

executed,  issues  a  burial  permit  or  a  removal 

permit  to  the  undertaker,  which  authorizes  liim  to  proceed  with  the 

interment  or  removal  of  the  body. 

3.  The  local  registrar  should  record  the  death  in  his  register  before 
issuing  a  permit,  as  he  is  thus  more  apt  to  detect  omissions.     He  may 


38  TUBERCULOSIS   IN   THE   UNITED  STATES. 

index  the  local  register  for  convenient  reference,  and  in  cities  he  fre- 
quently makes  a  weekly,  monthly,  or  annual  compilation  of  mortality 
statistics  for  local  sanitary  purposes.  Soon  after  the  close  of  the 
month  (e.  g.,  on  the  fourth  day  of  the  following  month  in  Mchigan, 
on  the  fifth  in  Pennsylvania)  he  sends  to  the  state  registrar  all  of  the 
original  certificates  of  death  registered  with  him  for  the  month  or,  if 
no  deaths  occurred,  makes  a  postal  card  report  of  "no  deaths." 

4.  The  state  registrar  receives  monthly  the  prompt  returns  of 

deaths  from  each  local  registration  oflB.ce,  and 
aeregisrar.  ^^  mcans   of  the  reports  of  "no   deaths"   is 

enabled  to  know  that  each  district  of  the  state  has  reported  all  of  the 
deaths  that  have  occurred.  He  examines  the  returns,  obtains  neces- 
sary corrections  for  items  imperfectly  filled  out,  and  in  general  sees 
that  the  law  is  uniformly  and  effectively  enforced  throughout  the 
state.  The  returns  are  indexed  and  such  statistical  compilations  are 
made  and  pubhshed  in  monthly  bulletins  and  annual  reports  as  may 
be  required  for  state  use. 

5.  Under  the  census  law,  the  Director  is  authorized  to  obtain  tran- 

scripts of  certificates  of  death  from  such  states 

Transcripts  for  the  Census.  i-,.        //         •       ,i         t  ,•  i>   ,i       -r\' 

and  cities  as  m  the  discretion  of  the  Director 
possess  records  affording  satisfactory  data  in  necessary  detail,"  and 
these  transcripts  are  made  out  for  each  death  upon  an  individual 
blank  in  the  exact  form  of  the  Standard  Certificate.  Formerly  these 
transcripts  were  sent  in  annually  or  semiannually,  but  an  effort  is 
being  made  to  secure  prompt  monthly  returns  to  Washington  of 
the  transcripts  from  the  registration  states  and  cities,  so  that  the 
annual  report  on  MortaHty  Statistics  may  be  compiled  and  pubhshed 
at  an  earHer  date. 

6.  On  arrival  at  the  Census  OflSce  the  transcripts  are  examined, 

and  corrections  of  imperfect  data  are  obtained 

Compilation  by  the  Census.  -  .,  ,  ,i  ,  •     ,  ji 

so  far  as  possible;  the  transcripts  are  then 
"edited,"  that  is,  the  numbers  corresponding  to  the  classification  of 
causes  of  death,  occupations,  etc.,  are  inserted  in  readiness  for  the 
next  process  of  compilation. 

7.  From  the  perfected  transcript  of  a  death  all  of  the  statistical 
information  required  for  compilation  is  transferred  to  a  card  by  means 
of  a  punch.  The  punched  cards  are  then  compiled  by  means  of 
electric  tabulating  machines,  which  record  on  many  dials  the  various 
items  necessary  for  the  statistical  tables.  The  resulting  tables, 
arranged  and  edited,  constitute  the  annual  report  on  Mortahty 
Statistics,  which  is  distributed  to  state  and  cit}'  sanitary  authorities, 
physicians,  foreign  governments,  etc.,  and  is  for  the  use  of  all  persons 
interested  in  the  condition  of  the  public  health  of  the  United  States. 


Uuq 

SB 

S 


PLACE  C 


County  of   — 
Townsiiip  of- 

or 

Village  of 


DEli 
City  of \ 

[If  dsath  occurs  away  fj 

USUAL  RESIDENC 

give  facts  called  for  un 

"  Special  information. 


rJEIiSONAJj 


SEX 


Maid 


DATE  OF  BIRTH 


24 


.._.t/i 


SINGLE,  MARRIED, 
WSDOWED,  OR  Dive 


BIRTHPLACE 

(State  or  country) 


NAME  OF 
FATHER 


BIRTHPLACE 
OF  FATHER 

(State  or  country) 


MAIDEN   NAME 
OF  MOTHER 


BIRTHPLACE 
OF  MOTHER 

(State  or  country) 


OCCUPATION 


THE  ABOVE  STATED 
BEST  OF  MY  KNO' 


(Informant)  

(Address) 


Filed 


.190 


PLACE  OF  DEATH 
County  of     -....-J)EN.VER«.__ 
Township  of 

Village  of 

^./'",           DENVER,  ,„„ 

City  of. -" 'No^ 

[If  death  occurs  away  from 
USUAL  RESIDENCE 

""Speclalfnfoma'tlon""]"        FULL    NAME  ._. 


3436 


STANDARD     CERXIFICAXE 

COLORADO 


1127  W.   Cedar 


-St.; Ward) 


a  Hospital  or  Institution, 
givo  its  NAME  Instead 
of  street  and  numberil 


FEUBON^L  ^ 


>  STATISTICAL  FAJBTICUJiAjaS 


'"°try)  Missouri 


(Slutour  country) 


(Informant)    

(Address) . 


MEDtOJ-L  OBnTIFICATE  OF  HJSATJI 


DATE  OF  DEATH 


Dec.   9,  1907.  jgO- 

"{Monih")"'""  "(D^y)""       (ToaV) 


I   HEREBY   CERTIFY,   That   I    attended  deceased  from 


.J90-. 


-to- 


that  I  last  saw  h.. —  alive  on 

and  that  dt.ath  occurred,  on  the  date  stated  abov< 
M.    The  CAUSE  OF  DEATH  was  as  follows 


-Pti^^m&tm-yy-Tubercttl-^g-ig-- 


..^, 


'SyrsV 


-190 (Addri 


SPECIAL  INFORMATION  only  for  HosplUls,  Inslltiillons,  Transients, 
r  Rocent  Resldonts, 


UNDERTAKER 


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TUBERCULOSIS   IN    Tlili    UNITED   STATES.  89 

It  is  evident  from  the  foregoing  outline,  that  accurate  mortahty 
statistics     are     dependent    upon    the     faithful 
service   and   cooperation   of   many   individuals.       Requ'S'tes    for    accurate 

^  1111  mortality  statistics. 

It  is  necessary  that  there  should  be — 

1.  Obedience  to  the  law  on  the  part  of  the  undertaker. 

2.  Care  in  filling  out  the  statement  of  age,  occupation,  etc.,  by  a 
relative  or  friend  of  the  deceased  person. 

3.  Care  and  special  knowledge  on  the  part  of  the  attending  physi- 
cian or  coroner  in  stating  the  cause  of  death. 

4.  Interest  and  care  on  the  part  of  the  local  registrar  in  seeing  that 
the  certificates  of  death  filed  with  him  are  completely  and  properly 
filled  out  and  that  all  deaths  that  occur  in  his  jurisdiction  are  promptly 
registered  and  returned  by  him  to  the  state  office.^ 

5.  Alert  supervision  by  the  state  registrar  so  that  the  law  will  be 
thoroughly  enforced  in  all  parts  of  the  state,  with  the  will  and  power 
to  compel  obedience  on  the  part  of  undertakers,  physicians,  and  local 
registrars  when  necessary. 

6.  Careful  examination  of  returns  by  the  state  registrar  and 
prompt  securing  of  missing  data  or  correction  of  imperfect  statements 
of  cause  of  death. 

7.  Accurate  copying  (which  implies  comparison)  of  the  original 
certificates  upon  the  transcripts  sent  to  the  Bureau  of  the  Census. 

8.  Prompt  examination  of  transcripts  upon  receipt  by  the  Bureau 
of  the  Census,  and  correspondence  for  corrections. 

9.  Careful  "editing,"  especially  for  classification  of  causes  of  death, 
by  expert  compilers  thoroughly  acquainted  with  the  International 
Classification  and  with  the  use  of  medical  terms. 

10.  Accurate  transferal  of  data  to  the  punched  tabulation  card. 
These  are  "compared  back"  with  the  original  transcripts  to  insure 
correctness. 

11.  Careful  tabulation  of  punched  cards.  Electrical  tabulating 
machinery  has  reduced  this  to  a  mechanical  basis  and  thus  largely 
eliminated  the  "personal  equation." 

12.  Lastly,  the  editorial  work  proper,  or  the  analysis  of  the  figures 
presented  in  a  registration  report.  The  analysis  is  subject  to  error, 
but  the  figures  themselves  stand  as  witnesses  of  their  own  significance. 

The  chief  difficulties  in  obtaining  accurate  statistics  of  the  mor- 
tality from  tuberculosis  (or  any  other  disease) 

for  the  United  States  are  due  to  the  following   .^"^^SSfZl^^Si:^. 
causes : 

1.  Adequate  laws,  with  the  requirement  of  compulsory  burial  per- 
mits, do  not  yet  exist  in  a  large  portion  of  the  United  States.  At- 
tempts to  collect  data  concerning  deaths  by  assessors,  or  through 

1  See  Census  pamphlet  No.  101,  "Practical  Registration  Methods,"  which  is  de- 
signed to  aid  the  local  registrar  in  his  work. 


40  TUBERCULOSIS   IN    THE    UNITED   STATES. 

county  officers,  or  by  direct  reports  from  physicians  or  undertakers, 
without  the  rigid  requirement  of  burial  permits  issued  by  a  local 
registrar,  are  futile  and  worse  than  useless  so  far  as  reliable  mortality 
statistics  are  concerned. 

The  remedy  for  this  lies  in  the  passage  and  enforcement  of  ade- 
quate laws,  and   the  American  Medical  Asso- 
Cooperation  for  extension   ciatiou,    the    Conference    of    Commissioners  on 

or  registration  area.  •  r-i 

Uniform  State  Laws,  and  the  American  Public 
Health  Association  have  united  with  the  Bureau  of  the  Census  in 
recommending  a  model  bill  for  the  consideration  of  state  legisla- 
tures at  their  approaching  sessions.  The  Bureau  of  the  Census  has 
been  earnestly  engaged  in  this  work — the  extension  of  the  registra- 
tion area — ever  since  its  establishment  on  a  permanent  basis  enabled 
it  to  plan  for  the  future,  instead  of  being  concerned  alone  with  the 
tabulation  of  past  results.  Its  efforts  in  this  respect  have  been 
attended  with  signal  success  in  Pennsylvania^  and  other  states,  and 
Congress  has  especially  commended  the  movement  in  the  following 
joint  resolution: 

JOINT    RESOLUTION     REQUESTING    STATE    AUTHORITIES    TO    COOPERATE    "WITH    CENSUS 
OFFICE  IN  SECURING  A  UNIFORM  SYSTEM  OF  BIRTH  AND  DEATH  REGISTRATION. 

Whereas  the  registration  of  births  and  deaths  at  the 

Resolution    by    the    Con-     ,-  j-ji-  j        -i  rc-i  j  •    t  x- 

c  ^u   TT  -f.  J  c.  tune  of  their  occurrence  furnishes  oincial  record  inf ormation 

gress  of  the  United  States. 

of  much  value  to  individuals;  and 

Whereas  the  registration  of  deaths,  with  information  upon  certain  points,  is  essential 
to  the  progress  of  medical  and  sanitary  science  in  preventing  and  restricting  disease 
and  in  devising  and  applying  remedial  agencies ;  and 

"\^Tiereas  all  of  the  principal  countries  of  the  civilized  •world  recognize  the  necessity 
for  such  registration  and  enforce  the  same  by  general  laws;  and 

"WTiereas  registration  in  the  United  States  is  now  confined  to  a  few  states,  as  a  whole, 
and  the  larger  cities,  under  local  laws  and  ordinances  which  differ  widely  in  their 
requirements;  and 

WTiereas  it  is  most  important  that  registration  should  be  conducted  under  laws  that 
will  insure  a  practical  uniformity  in  the  character  and  amount  of  information  avail- 
able from  the  records ;  and 

Whereas  the  American  Public  Health  Association  and  the  United  States  Census 
Ofl&ce  are  now  cooperating  in  an  effort  to  extend  the  benefits  of  registration  and  to 
promote  its  efhciency  by  indicating  the  essential  requirements  of  legislative  enact- 
ments designed  to  secure  the  proper  registration  of  all  deaths  and  births  and  the  col- 
lection of  accurate  vital  statistics,  to  be  presented  to  the  attention  of  the  legislative 
authorities  in  nonregistration  States,  with  the  suggestion  that  such  legislation  be 
adopted:  Now,  therefore, 

Resolved  by  the  Senate  and  House  of  Representatives  of  the  United  States  of  America  in 
Congress  assembled,  That  the  Senate  and  House  of  Representatives  of  the  United  States 
hereby  expresses  approval  of  this  movement  and  requests  the  favorable  consideration 
and  action  of  the  State  authorities,  to  the  end  that  the  United  States  may  attain  a 
complete  and  uniform  system  of  registration. 

Approved  February  11,  1903. 

^  See  Census  pamphlet  No.  106,  "Extension  of  the  Registration  Area  for  Births  and 
Deaths."  See  also  Census  pamphlet  No.  108,  ''Legal  Importance  of  Registration  of 
Births  and  Deaths,"  copies  of  which  are  obtainable  at  the  Census  exhibit  of  the 
International  Congress  on  Tuberculosis. 


TUBERCULOSIS   IN    THE   UNITED   STATES.  41 

2.  Where  fairly  efficient  laws  exist  there  is  frequent  difficulty  in 
obtaining  from  physicians  correct  statements  of  the  causes  of  death. 
This  is  due  to  two  reasons:  (1)  Lack  of  a  uniform  and  plainly  com- 
prehensible blank  for  the  medical  statement  of  cause  of  death,  with 
expHcit  instructions  for  its  use;^  (2)  lack  of  uniform  nomenclature^  of 
diseases,  which  results  in  a  difficulty  in  understanding  just  what  the 
physician  meant  in  his  statement. 

The  question  of  the  form  of  blank  has  been  solved,  to  a  considerable 
extent,  by  the  adoption  of  the  Standard  Certifi- 
cate by  many  states  and  cities.     Unfortunately   ,  Uniform  certificate  of  dea.h 

'^  ,  ,  .  *'      to  be  adopted. 

all  do  not  use  it,  and  the  Section  on  Vital  Statis- 
tics of  the  American  Public  Health  Association  has  rendered  a  great 
service  by  recommending,  at  its  recent  meeting  at  Winnipeg,  August, 
1908,  the  exclusive  use  of  an  improved  form  of  the  Standard  Certifi- 
cate byall  registration  offices  in  the  United  States  after  January  1, 1910. 
The  question  of  nomenclature  of  diseases  has  also  been  taken  up 
in  a  practical  way  by  a  committee  of  the  Ameri- 
can Medical  Association,  whose  chairman  is  Dr.      Uniform  nomenclature  of 

'  _  ^  diseases  m  preparation. 

Frank  P.  Foster,  of  New  York.  This  committee 
is  cooperating  with  special  committees  appointed  by  other  national 
medical  organizations,  and  with  the  Government  medical  services 
(Army,  Navy,  and  Public  Health  and  Marine-Hospital  Service),  and 
with  the  Bureau  of  the  Census.  As  a  result  of  its  labors,  it  will  be 
possible  for  the  physicians  of  the  United  States  to  have  a  standard 
of  reference  for  the  use  of  medical  terms,  and  for  the  Bureau  of  the 
Census  to  cooperate  with  state  and  city  officials  in  recommending  the 
use  of  authorized  terms  to  report  causes  of  death.^  The  vital  statis- 
tics of  the  future  must  be  statistics  of  greater  precision,  for  they  are 
to  be  the  working  tools  of  an  aggressive  scientific  public  health  ad- 
ministration. 

III. — How  THE  International  Congress  on  Tuberculosis  Can 
Promote  the  Prevention  of  Tuberculosis  by  Insisting  upon 
THE  Necessity  for  Complete  Registration  of  Deaths  through- 
out THE  United  States. 

Une  statistique  generale  de  la  tuberculose  ne  peut  etre  etablie  convenablement  qii'au 
moyen  d'une  statistique  generale  des  causes  de  decfes  Etablie  selon  une  nomenclature 
comparable  de  pays  a  pays  et  sp^cifiant  les  principales  maladies  qui  peuvent  etre  con- 
fondues  avec  la  tuberculose  (bronchite  clironique,  m^ningite,  etc.).  La  nomencla- 
ture dite ' '  internationale  "  est  particuli^rement recommandable. — Dr.  Jacques  Bertillon. 

'  See  Census  pamphlet  No.  107,  "Modes  of  Statement  of  Causes  of  Death  and  Dura- 
tion of  Illness  upon  Certificates  of  Death." 

-  The  International  Classification  of  Causes  of  Death  is  not  a  complete  nomenclature 
of  diseases. 

^  As  by  Census  pamphlet  No.  102,  "Tlelation  of  Physicians  to  Mortality  Statistics,'^ 
a  new  edition  of  which  will  be  prepared. 


42  TUBERCULOSIS  IX   THE  UNITED  STATES. 

The  above  quotation  from  Doctor  Bertillon's  valuable  paper  on 
„    .  .      ,    ,      ,   .       '  ^Comment  doivent  etre  etablies  les  statistiques 

Statistics  of  tuberculosis  a  .  ^  ^ 

part  of  general  mortality  sta-  relatives  a  la  tuberculose  dans  les  viUes,  dans  lea 
*^'^"-  campagnes,  dans  les  hopitaux,  dans  les  sanato- 

riums,"  read  before  the  International  Institute  of  Statistics  at  its 
session  held  at  Copenhagen  in  1907,  is  presented  for  its  direct  bear- 
ing upon  the  proper  method  of  obtaining  general  statistics  of  tuber- 
culosis. Such  statistics  are  a  part  of  general  mortaUty  statistics,  and 
the  whole  Hst  of  causes  of  death  must  be  studied  in  connection  with 
them.  Moreover,  in  the  United  States  we  must  first  obtain  our  gen- 
eral mortality  statistics  for  a  considerable  part  of  the  country,  since  it 
is  useless  to  expect  statistics  for  an  individual  disease  unless  all  deaths 
are  registered  as  they  occur. 

The  following  abstract  of  the  address  of  the  chief  statistician  for 
vital  statistics  of  the  Bureau  of  the  Census  as  chairman  of  the  Sub- 
section on  "Collection  of  Statistics"  of  Section  VI,  ''State  and 
Municipal  Control  of  Tuberculosis,"  of  the  International  Congress  on 
Tuberculosis,  contains  a  preUminary  draft  of  certain  resolutions  whose 
sanction  by  the  Congress,  and  whose  practical  recognition  by  the 
sanitary  agencies  now  interested  in  the  control  of  tuberculosis,  would 
be  of  the  utmost  service  in  securing  adequate  mortality  statistics  for 
the  United  States,  and  thus  providing  the  means  by  which  the 
warfare  against  tuberculosis,  and  against  all  other  diseases  which 
may  be  controlled  by  man,  will  be  vitally  aided : 

COLLECTION    OF    STATISTICS    OF    TUBERCULOSIS. 

[Abstract.] 

In  efforts  for  the  "State  and  Mimicipal  Control  of  Tuberculosis," 
„    .  r  ,    ,       ,    the  first  and  most  obvious  step  is  to  ascertain 

Registration  of  deaths  and  <.         i  i      • 

notification  of  sickness  from  the  amouut  of  tubcrculosis  present  m  a  given 
tuberculosis.  countrv,  statc,  or  city;  the  forms  and  conditions 

of  its  occurrence;  its  natural  fluctuations;  and  thus  to  be  enabled  to 
measure  the  value  of  procedures  undertaken  for  its  prevention  and 
restriction.     This  imphes — 

(a)  Registration  (notification)  of  all  cases  of  tuberculoeis. 

(b)  Registration  of  all  deaths  from  tuberculosis. 
Subdix^ded  by  character  of  area,  ve  have — 

1.  National  registration  of  tuberculosis — 

(a)  Sickness. 

(b)  Deaths. 

2.  State  registration  of  tuberculoeis — 

(a)  Sickness. 
(6)  Deaths. 

3.  Municipal  registration  of  tuberculosis — 

(a)  Sickness. 
(6)  Deaths. 


TUBERCULOSIS  IN  THE  UNITED  STATES.  43 

The  registration  of  sickness  and  deaths  from  tuberculosis  is  of 
value  to  a  sanitary  administration  not  only  for  the  statistical  informa- 
tion afforded  but  as  an  administrative  means  whereby  the  health 
officer  may  come  into  close  touch  with  cases  of  tuberculosis,  as  soon 
as  they  are  recognized  by  the  attending  physicians,  and  thus  be 
enabled  to  instruct  the  patients,  their  families,  friends,  and  neighbors 
in  regard  to  the  necessary  precautions  to  prevent  infection  of  other 
persons,  and  to  give  helpful  general  advice. 

It  is  not  worth  while  to  attempt  anything  less  than  complete  regis- 
tration of  all  cases  of  sickness  and  death  from 
tuberculosis.  This  is  especially  true  from  the  3e„^°a7''''  '*"''''"  "■'  "' 
point  of  view  of  the  statistical  data  collected. 
Imperfect  statistics  based  upon  incomplete  returns  may  be  misleading 
and  worse  than  useless.  Accurate  registration  of  sickness  from  tuber- 
culosis should  be  of  much  greater  value  to  a  sanitary  administration 
than  the  accurate  registration  of  deaths,  and  is  of  particular  impor- 
tance to  the  tuberculous  sick.  For  the  individual  the  accounts  are 
closed  when  it  comes  to  the  mortality  statistics.  The  registration  of 
all  cases  of  sickness  from  tuberculosis  or  from  any  other  disease  pre- 
sents extreme  difficulties,  however,  especially  in  the  Unifed  States; 
it  is  futile  to  expect  even  approximately  correct  returns  of  sickness  when 
the  deaths  themselves  are  not  recorded,  as  is  the  case  in  a  large  portion 
of  the  United  States.  The  first  and  absolutely  necessary  step  is, 
therefore,  to  insure  the  complete  registration  of  all  deaths,  including 
those  of  tuberculosis,  and  the  Congress  on  Tuberculosis  should  com- 
mend, and  its  members  in  the  United  States  should  earnestly  support, 
the  organized  efforts  made  to  secure  the  extension  of  the  registration 
area  in  this  country.  The  following  resolutions  may  be  submitted 
under  this  head: 

A.   INDISPENSABLE   IMPORTANCE    OF   REGISTRATION   OF   SICKNESS   AND   DEATHS 
FROM  TUBERCULOSIS. 

1.  The  registration  of  sickness  and  deaths  from  tuberculosis  is  of  indispensable  impor- 
tance to  a  sanitary  administration  which  undertakes  to  com- 
bat this  disease,  and  the  registration  (notification)  of  sickness    ■    .  ^^  •^'"^0'    r^ 

from  tuberculosis  should  be  of  special  benefit  to  the  tuber- 
culous sick,  to  their  medical  attendants,  and  to  theh  families  and  friends.  For  its  full 
value,  especially  for  administrative  and  statistical  purposes,  such  registration  ought 
to  be  complete;  and  it  should  be  considered  a  paramount  duty  by  legislators,  sanitary 
officials,  the  medical  profession,  and  the  press  and  public,  to  bring  about  such  complete 
and  effective  registration  of  all  deaths  and  sickness  from  tuberculosis. 

2.  The  first  step,  in  the  United  States,  must  be  to  secure  the  proper  registration  of  all 
deaths,  from  whatever  cause;  the  registration  of  deaths  from  tuberculosis  is  merely  a 
part,  although  a  very  important  one,  of  the  general  problem.  It  is  useless  to  attempt 
adequate  registration  of  sickness  when  deaths  are  not  registered .  The  organized  efforts 
and  cooperation  of  the  American  Medical  Association,  the  American  Public  Health 
Association,  the  Conference  of  Commissioners  on  Uniform  State  Laws,  the  United 


44  TUBERCULOSIS   IN    THE   UNITED   STATES. 

States  Public  Health  and  Marine-Hospital  Service,  and  tlie  United  States  Bureau  of 
the  Census,  to  secure  the  adoption  and  enforcement  of  adequate  laws  for  the  proper 
registration  of  deaths  and  the  extension  of  the  registration  area  of  the  United  States,'are, 
therefore,  most  cordially  commended  by  the  Congress  on  Tuberculosis  as  affording  the 
first  and  absolutely  indispensable  means  for  the  control  and  final  suppression  of  tuber- 
culosis in  this  country,  and  all  who  are  interested  in  the  movement  for  its  control  are 
earnestly  requested  to  help  to  secui-e  the  necessaiy  legislation,  and  to  support  it  when 
secured  and  to  seek  to  educate  public  sentiment  on  this  subject,  to  the  end  that  the 
United  States  may  attain  a  complete  and  uniform  system  of  registration. 

The  comparability  of  international  statistics  of  tuberculosis  should 
Accurate  and  internation-   ^6  assured.     This  requires  a  knowledge  of  the 
ally  comparable  statistics  of   various  systcms  of  classification  ia  use,  and  also 
tuberculosis  required.  ^^   ^^^   tendcncj   amoug   phjsicians   to   report 

deaths  under  terms  that  may  be  classified  under  titles  having  no 
apparent  relation  to  tuberculosis.  The  use  of  the  International 
Classification  should  be  indorsed/  as  its  general  acceptance  will  re- 
move many  of  the  difficulties  now  inherent  in  comparing  the  statis- 
tics of  one  country  with  those  of  another.  The  International  Com- 
mission for  regular  decennial  revision  of  the  International  Classi- 
fication will  meet  in  1909,  and  the  Congress  on  Tuberculosis  should 
make  specific  recoimnendations  relative  to  the  form  in  which  the 
statistics  of  morbidity  and  mortality  from  tuberculosis  should  be 
presented,  so  that  they  may  show  most  satisfactorily  the  true  inci- 
dence of  the  disease  upon  the  various  classes  of  population,  and  under 
different  environments,  and  may  be  more  closely  in  harmony  with 
practical  clinical  classifications.  The  medical  profession  should  be 
educated  to  present,  and  the  people  to  demand  the  TRUTH  about 
the  occurrence  of  this  disease;  the  failure  to  report  tuberculosis  as  a 
cause  of  sickness  or  death,  when  such  reports  are  required  by  law,  or 
the  making  of  a  false  report  to  conceal  the  presence  of  this  disease, 
should  consequently  be  considered  a  dishonorable  professional  act 
on  the  part  of  any  medical  attendant;  and  any  regulations  of  insur- 
ance companies  or  other  institutions  tending  to  the  falsification  of  the 
reports  of  tuberculosis  should  be  considered  as  contrary  to  public 
policy.     The  following  resolutions  are  proposed: 

B.    NECESSITY   FOR   UNIFORM   STATISTICAL   CLASSIFICATION    AND    ACCURATE    REPORTING 

OF  TUBERCULOSIS. 

1.  All  Statistics  of  tuberculosis,  whether  national,  state,  or  municipal,  and  also  sta- 
tistics of  hospitals  and  institutions,  should  be  thoroughly 
Preliminar)'  draft  of  reso-    (^oj^pa^able,  both  for  the  statistics  of  sickness  and  of  deaths. 

lutions  proposed.  _..,,,  ,^1  i  t 

Physicians  should  confine  themselves  to  the  accepted  terms 

of  the  standard  classification,  and  doubtful  reports  ("possibly  tuberculous")  should 

be  systematically  investigated  by  sanitary  and  registration  authorities.     A  penalty 

^  At  the  recent  meeting  of  the  American  Medical  Association  at  Chicago,  June,  1908, 
the  House  of  Delegates  imanimously  resolved  "that  the  International  Classification  of 
Diseases  and  Causes  of  Death  be  recommended  for  all  official  morbidity  and  mortality 
statistical  reports." 


TUBERCULOSIS   IN    THE   UNITED   STATES.  45 

should  be  provided  for  false  statements  intended  to  conceal  the  presence  of  tubercu- 
losis, the  making  of  which  should  be  considered  a  matter  of  professional  and  personal 
dishonor;  and  all  legal  requirements  relative  to  insurance  and  other  matters  tending 
to  falsification  of  official  statements  of  causes  of  illness  or  death  should  be  held  contrary 
to  public  policy. 

2.  The  Congress  on  Tuberculosis  should  endeavor  to  secure  the  adoption  in  all  sta- 
tistical classifications  of  a  standard  classification  of  tuberculosis,  and  for  this  purpose 
should  appoint  a  Committee  to  consider  the  various  forms  now  in  use  and  to  present 
its  recommendations  to  the  International  Commission  for  the  Revision  of  the  Inter- 
national Classification  of  Causes  of  Death  and  Sickness,  which  meets  in  1909,  and  also 
to  the  registration  authorities  of  the  governments  employing  other  systems  of  classifi- 
cation, to  the  end  that  as  soon  as  possible  a  uniform  classification  of  tuberculosis  may 
be  used  by  all  of  the  countries  of  the  world. 


SlXry  VEAKS  O?  tuberculosis  Call  forms) 


DEATH  RATES  PER  100,000   Of  POPUUA.T10W 

i^  Annual  r<port..r<jistrafi.n  «r<a     —  NASSACKUStTTS 
"        •    D<«nmiiCKp.rM.r(9istroll«ilir(a  ^otX-lANDANOUAltS 
'*        •    D«..miolt<i.«r(.H.f»r.-«roHiihra<nf.'f  r<9i«tratltnot« 


ProporHonal  6eaHis  from  TUBEReUuOSlS 
per  1.000  6{a^hs  prom  qU  causes 


-"■Annual  rtparts. «aistn 


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i 

REFERENCE  TABLES. 


(47) 


TUBERCULOSIS  IN   THE   UNITED   STATES. 


49 


Oj  O  (0  M  C8  E'^StJ 
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50 


TUBERCULOSIS   IN    THE   UN'ITED   STATES. 


1 


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Deaths 
from 
tubercu- 
losis 
(all 
forms) 
per  1,000 
of  total 
deaths. 

1 

o 

Death 
rate  for 
tubercu- 
losis (all 
forms) 

per 
100,000 
of  popu- 
lation. 

(M 

to 

Number 

of 
deaths 
from 
tubercu- 
losis 
(all 
forms). 

s 

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Per  cent 
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TUBERCULOSIS  IN   THE  UNITED  STATES. 


51 


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52 


TUBERCULOSIS   IN   THE   UNITED   STATES. 


Table  2. — Death  rai-es  from  tuberculosis  of  lungs  in  the  registration  area  of  the  United 
States  and  ni  certain  foreign  countries  {during  recent  years):  1902  to  1906. 

j  NUMBEE    OF    DEATHS    FEOM    TXTBEECULOSIS    OF   LUXGS    PEE 
!  100,000  OF  POPCLATIOK. 


1^^- 


United  States  (registration  area 

Anstralasia 

Australian  Commonwealth . . 

New  South  Wales 

Queensland 

South  Australia 

Tasmania 

Victoria 

Western  Australia 

■     •  New  Zealand 

Austria 

Belgium 

Cevlon 

Chile 

German  Empire 

Italys 

Jamaica 

Japan 

Netherlands 

Norway 

Servia 

Spain 

Switzerland 

United  Kingdom 

—-.-'England  and  Wales 

Scotland 

.Jreland 


Annual  '. 

average:  • 
1901  to    ■ 

1902 

1903 

1904 

1903 

1906 

1905. 

169.9  1 

163.2 

165.7 

177.3 

168.2 

159.4 

85.6 

89.1 

86.8 

85.9 

76.5 

75.7 

SS.9 

91.5 

90.4 

89.2 

80.8 

7&7 

80.2  ; 

80.6 

86.8 

81.2 

70.1 

66.  a 

81.3 

89.2 

7a  4 

79.0 

75.5 

67.8 

80.4  ; 

81.1 

81.8 

79.0 

75.2 

81.6 

63.3 

58.0 

63.1 

63.2 

74.8 

65.9 

111.6 

116.6 

110.9 

111.1 

101.9 

9^9 

72.6 

71.0 

65.1 

83.7 

64.7 

82.6 

69.9 ; 

77.3 

69.5 

70.8 

57.0 

62.1 

334  8  ■ 

337.4 

336.2 

331.4 

0) 

(1) 

11&2  i 

131.6 

108.6 

109.1 

107.5 

(•) 

93.0  : 

90.8 

91.3 

92.6 

95.7 

104. « 

(?)        i 

0) 

245.1 

(1) 

201.7 

(») 

185.8  I 

187.7 

187.3 

182.6 

179.3 

(•) 

114.9  1 

10&8 

111.6 

117.4 

iia2 

148.8 

153.7  1 

147.7 

155.2 

163.0 

152.2 

160.4 

14a  3 

143.4 

144.9 

U46.4 

<159.5 

« 

133.4 

132.0 

132.0 

129.4 

135.7 

133.7 

196.4 

188.5 

198.2 

197.4 

203.5 

0) 

279.7  1 

265.6 

277.5 

277.0 

332.5 

287.4 

147.8 : 

186.0 

144.0 

<lo0.9 

M41.1 

M44.4 

188.6  : 

187.0 

188.0 

188.2 

191.9 

0) 

133.8  ■■ 

135.0 

132.9 

136.5 

126.2 

(}) 

121.  5  : 

123.3 

120.3 

124.0 

114.0 

115.0 

144.5  ■ 

145.0 

144.8 

145.6 

136.3 

(}) 

215.3 

212.0 

216.6 

223.4 

209.9 

203.6 

1  N'o  figures  available;  average  only  for  years  shown. 
-  Annual  average  not  shown  for  less  than  three  years. 
3  Includes  general  tuberculosis. 
*  Rates  based  on  provisional  figures. 

Table  3. — Deaths,  death  rates,  and  per  cent  of  deaths  from  the  various  forms  of  tuber- 
culosis (.International  Classification)  in  the  registration  area  of  the  United  States  {during 
recent  years):  1902  to  1907. 


FOEM  OF  DISEASE. 


Annual . 
aver-  ■ 
age:     : 

1901  to  !i 
1905.    li 


1902 


1903 


1901       1905 


1906 


1907 


Tuberculosis  (aU  forms). 


Tuberculosis  of  lungs 

Tuberculosis  of  larynx 

Tuberculous  meningitis 

Abdominal  tuberculosis 

Pott's  disease 

Tuberculous  abscess 

TMiite  swelling 

Tuberculosis  of  other  organs. 
General  tuberculosis 


KUMBEE  OF  DEATHS  FEOM  TAEIOUS  FOEMS  OF  TUBEE- 
CtTLOSIS. 


Tubercolosis  (all  for.-ns 

Tuberculosis  of  lungs 

Tuberculosis  of  larynx 

Tuberculous  meningitis 

Abdominal  tuberculosis 

Pott's  disease 

Tuberculous  abscess 

■Uliite  swelling 

Tuberculosis  of  other  organs. 
General  tuberculosis 


62,835 


55,251 

557 

2,905 

1,946 

492 

56 

234 

467 

926 


58,938  !  61,487  ,  66,797  |  65,352  i  75,512  |     76,650 


52,079     53,910  i  58,763  ,  56,770 


541 
2,674 
1,817 
421 
39 
237 
391 
739 


539 
2,905 
1,854 

516 
72 

224 

465 
1,002 


570 

3,025 

2.098 

'519 

62 

241 

545 

974 


610 
3,264 
2,193 

563 
61 

261 

539 
1,091 


65,341 

645 

3,938 

2,663 

618 

49 

315 

685 

1,258 


DEATH  BATE  PEE  100,000  OF  POPTILATIOX. 


66,374 

690 

4,062 

2,629 

594 

65 

269 

713 

1,254 


193.2  1 

184.7 

189.0 

201.6 

193.6 

184  2 

183.6 

169.9  1 

163.2 

165.7 

177.3 

168.2 

159.4 

158.9 

1.7  ' 

1.7 

1.7 

1.7 

1.8 

1.6 

1.7 

a  9 1 

a  4 

a  9 

9.1 

9.7 

9.6 

9.7 

6.0  ; 

5.7 

5.7 

6.3 

6.5 

6.5 

6.3 

L5  1 

1.3 

1.6 

1.6 

1.7 

1.5 

1.4 

0.2  ! 

0.1 

0.2 

0.2 

0.2 

0.1 

0.2 

0.7  1 

1.4 

0.7 

0.7 

0.7 

0.8 

0.8 

0.6 

1.2 

1.4 

1.6 

1.6 

1.7 

1.7 

2.8 

2.3 

3.1 

2.9 

3.2 

3.1 

3.0 

TUBERCULOSIS  IN   THE   UNITED   STATES. 


58 


Table  3. — Deaths,  death  rates,  and  per  cent  of  deaths  from  the  various  forms  of  tuber- 
culosis (International  Classification)  in  the  registration  area  of  the  United  States  (during 
recent  years):  1902  to  1907 — Continued. 


FORM   OF  DISEASE. 


Annual  | 

aver- 

age:   1 

1902 

1908 

1904 

1905 

1906 

1901  to  1 

1905.    1 

1 

1907 


PER  CENT  OF  TOTAL  DEATHS  FROM  ALL  FORMS  OF^UBEB- 
CULOS18. 


Tuberculosis  (all  forms) 

Tuberculosis  of  lungs 

Tuberculosis  of  larynx 

Tuberculous  meningitis 

Abdominal  tuberculosis 

Pott's  disease 

Tuberculous  abscess 

White  swelling 

Tuberculosis  of  other  organs. 
General  tuberculosis 


100.0 


87.9 
0.9 
4.6 
3.1 
0.8 
0.1 
0.4 
0.7 
1.5 


0.9 
4.5 
3.1 
0.7 
0.1 
0.4 
0.7 
1.3 


100.0       100.0 


100.0  I     100.0 


87.7 
0.9 
4.7 
3.0 
0.8 
0.1 
0.4 
0.8 
1.6 


88.0 
0.9 
4.5 
3.1 
0.8 
0.1 
0.4 
0.8 


86.9 
0.9 
5.0 
3.4 
0.9 
0.1 
0.4 
0.8 


0.9 
5.2 
3.5 
0.8 
0.1 
0.4 
0.9 


100.0 


86.6 
0.9 
5.3 
3.4 
0.8 
0.1 
0.4 
0.9 
1.6 


Table  4. — Death  rates,  by  sex,  and  as  urban  and  rural,  from  tuberculosis  of  lungs^for 
the  registration  states:  1900  and  1890. 


REGISTRATION  STATE. 


Total,  1900. 
1890. 


Connecticut,  1900. 
1890. 


District  of  Columbia,  1900. 
1890. 


NUMBER  OF  DEATHS  FROM  TUBERCtTLOSIS  OF  LtTNGS  PER  100,000  OF  POP- 
ULATION. 


Aggregate. 


Total.     Cities.    Rural 


175.9 
249.0 


168.3 
233.6 


305.3 
359.0 


Maine,21900 164.9 


Massachusetts,  1900. 
1890. 

Michigan,^  1900 


New  Hampshire,  1900. 
1890. 


New  Jersey,  1900. 
1890. 


New  York,  1900. 
1890. 


Rhode  Island,  1900. 
1890. 


Vermont,  1900. 
1890. 


186.2 
267.1 


100.7 


152.3 
193.6 


180.1 
234.5 


194.1 
247.7 


195.3 
266.6 


152.5 
198.8 


204.8 
293.5 


182.7 
272.6 


305. 3 
359.0 


191.7 


193.7 
279.4 


lie.: 


176.2 
191.9 


202.2 
268.9 


221.4 
306.6 


208.3 
294.9 


160.9 
243.9 


134.1 
181.0 


141.8 
205.8 


159.4 


162.5 
227.0 


94.1 


137.3 
194.3 


151.1 
189.4 


137.3 
152.3 


170.0 
227.6 


151.2 
194.7 


257. 


176.8 
245.7 


334.1 
403.3 


149.3 


202.5 
265.2 


84.8 


142.2 
171.5 


194.3 
247.1 


221.3 
264.3 


207.1 
275.6 


137.0 
155.3 


Males. 


Females. 


Total.     Cities.    Rural.  |  Total.     Cities.    Rural 


234.3 

318.0 


124.9 

168.6 


200.2 
301.4 


334.1 
403.3 


208.1 
276.1 


119.6 


173.0 
176.5 


232.0 
300.3 


265.3 
343.2 


225.5 
320.2 


168.6 
221.5 


134.3 
206.7 


139.6 


185.3 
230.4 


71.2 


124.0 
169.6 


145.6 
178.7 


132.4 
141.2 


172.5 
216.2 


132.4 
149.6 


163.3 

240.4 


159.8 
221.7 


279.4 
318.7 


180.8 


170.7 
268.9 


162.5 
215.3 


165.8 
221.9 


167.2 
231.2 


183.9 
258.1 


168.5 
244.0 


176.4 
270.1 


143.8 
193.6 


165.4 
244.9 

149.6 
204.9 

279.4 
318.7 

184.0 

180.1 

180.2 
282.4 

140.0 
223.8 

113.8 

119.4 

179.1 
205.6 

151.3 
219.6 

172.7 
238.2 

156.7 
200.3 

178.8 
271.5 

142.4 
163.8 

192.1 
271.6 

167.4 
238.8 

153.7 
264.4 

171.0 
242.0 

1  Identical  with  consumption  as  shown  in  the  diagram;  the  latter  term  was  employed  in  the  Mor- 
tality Statistics  of  the  Census  up  to  the  close  of  the  census  year  1899-1900. 
'  Nonregistration  in  1890. 


CONSUMPTION 

NUMBER  OF  DEATHS  PER  100,000  OF  POPULATION 

FOR   CITIES  AND   RURAL   DISTRICTS 

IN  THE  REGISTRATION  STATES:  I900  AND  f890 


ACCRECATE 


REGISTRATION 
STATES 


TOTAL 


NEW  YORK 


RHODE  ISLAND 


NEW  JERSEY 


MASSACHUSETTS 


MAINE 


CONNECTICUT 


NEW  HAMPSHIRE 


VERMONT 


MICHIGAN 


1500 


MALES 

200   100 


1890 


»M£S 
300  200   100 


FQMALES 
100   200  300 


CITIES    I       {  RURAL 


TUBEKCULOSIS  IN   THE   UNITED   STATES. 


55 


Table  5. — Death  rates,  by  sex,  for  the  registration  area  and  registration  states  {aggregate, 
urban,  and  rural)  from  tuberculosis  of  lungs:  1900  and  1890. 


NUMBER 

OF    UEATUS    FROM    TUBERCULOSIS    OF    LUNGS    PEE 
100,000  OF  POPULATION. 

AREA. 

15  to  44  years. 

45  to  64  years. 

65  years  and  over. 

1900 

1890 

1900 

1890 

1900           1890 

252.4 
265.3 
239.5 

239.8 
251.5 
228.2 

276.8 
311.2 
243.9 

179.1 
158.1 
201.1 

320.1 
324.5 
315.7 

324.8 
327.0 
322.7 

380.7 
404.5 
358.2 

227.4 
197.1 
258.2 

232.5 
290.7 
173.1 

208.4 
253.1 
163.6 

257.9 
337.2 
181.8 

151.4 
160.6 
141.6 

319.3 
384.5 
254.8 

310.2 
372.1 
250.5 

389.1 
487.1 
296.5 

212.3 
232.5 
192.4 

260. 1             369. 0 

293.9             410.0 

230.0            3.32.3 

246. 6             360. 5 

Males                           

269.0            381.1 

226. 2            341. 9 

264.2             401.3 

333. 5            458. 8 

210.3            356.2 

Rural              

233. 6             330. 7 

228. 0            331. 3 

239.  4            330. 2 

Table  6. — Proportional  deaths  from  each  form  of  tuberculosis  {International  Classifica- 
tion) at  certain  age  periods  for  the  registration  area:  1900  to  1904. 


PROPORTION  OF  DEATHS  IN  EACH  AGE  PERIOD  PER  1,000  AT  KNOWN  AGE. 

AGE. 

Tuber- 
culosis 

(all 
forms) . 

Tuber- 
culosis 

of 
lungs. 

Tuber- 
culosis 

of 
larynx. 

Tuber- 
culous 
menin- 
gitis. 

Ab- 
domi- 
nal 
tuber- 
culosis. 

Pott's 
dis- 
ease. 

Tuber- 
culous 

ab- 
scess. 

Wtiite 
swell- 
ing. 

Tuber- 
culosis 
of  other 
organs. 

Gen- 
eral 
tuber- 
culosis. 

All  ages 

1,000 

1,000 

1,000 

1,000 

1,000 

1,000 

1,000 

1,000 

1,000 

1,000 

Under  1  year 

Under  5  years 

5  to  14  years 

15  to  24  years 

25  to  34  years 

35  to  44  years 

45  to  64  years 

65  years  and  over  . . 

30.1 

68.8 
35.8 
204.1 
267.2 
189.9 
179.2 
55.0 

14.3 

31.6 
24.9 
213.8 
284.9 
201.4 
187.2 
56.2 

10.5 

20.6 
12.4 
129.3 
270.6 
242.6 
245.3 
79.2 

277.3 

673.8 
158.0 
62.3 
47.1 
30.9 
22.0 
5.9 

103.7 

195.6 
82.7 
173.1 
168.0 
133.5 
175.3 
71.8 

53.2 

151.8 
208.9 
161.3 
144.5 
111.2 
157.4 
64.9 

76.9 

123.1 
65.4 
153.8 
192.3 
123.1 
242.3 
100.0 

24.3 

100.7 
264.4 
205.0 
125.0 

97.1 
136.7 

71.1 

43.8 

101.3 
71.6 
147.9 
188.4 
153.1 
223.2 
114.5 

73.8 

171.9 
86.2 
206.4 
199.9 
145.4 
143.5 
46.7 

56 


TUBEECULOSIS  IN   THE   UNITED  STATES. 


Table  7. — Relative  iviportance  of  tuberculosis  as  a  cause  of  death  at  specified  age  periods 
in  the  registration  area:  1907. 

U)  AT  ALL  AGES. 


CAUSE  OF  DEATH. 


PEE  CENT  OF  DEATHS  AT  ALL 
AGES. 


Females. 


All  eansea 

Ty-phoid  fever 

Whooping  cough 

Diphtheria  and  croup 

Tuberculosis  (all  forms) 

Tuberculosis  of  lungs 

Cancer 

Meningitis 

Apoplexy 

Paralysis 

"  Convulsions  " 

Heart  disease 

Bronchitis 

Pneumonia  (aU  forms) 

Diarrhea  and  enteritis 

Cirrhosis  of  liver 

Nephritis  and  Bright's  disease. 

Premature  birth 

Congenital  debility 

Old  age 

Violence 

Ill-defined  causes 

All  other  causes 


(B)  UNDER  15  YEARS  OF  AGE. 


C.YUSE  OF  DEATH. 


All  causes 

Typhoid  fever 

Measles 

Scarlet  fever 

Whooping  cough 

Diphtheria  and  croup 

Tuberculosis  (all  forms) 

Tuberculosis  of  lungs 

Tuberculous  meningitis 

Meningitis 

"  Convulsions  " 

Heart  disease 

Bronchitis 

Pneumonia  (all  forms) 

Diarrhea  and  enteritis 

Congenital  malformation  of  heart  (cyanosis) 

Premature  birth 

Congenital  debility 

Violence 

m-defined  causes , 

AU  other  causes 


PEE  CENT   OF  DEATHS   UNDEE 
15  YEAES. 


Total. 


100.0 


1.0 
1.9 
1.9 
2.3 
4.5 
4.0 
1.7 
1.6 
3.8 
3.3 
1.1 
3.0 
13.1 
21.0 
1.9 
7.3 
7.3 
5.2 
4.2 
13.4 


Males. 


100.0 


0.9 
1.8 
1.7 
2.0 
4.4 
3.6 
1.4 
1.5 
3.8 
3.4 
1.1 
2.9 
12.9 
20.9 
2.0 
7.5 
7.6 
5.9 
4.1 
13.5 


Females. 


100.0 


1.1 
2.0 
2.1 
2.7 
4.7 
4.4 
2.1 
1.6 
3.9 
3.1 
1.2 
3.0 
13.2 
21.0 
L8 
7.0 
7.0 
4.3 
4.3 
13.3 


TUBERCULOSIS   IN    THE   UNITED   STATES. 


57 


Tablb  1  .—Relative  importance  of  tuberculosis  as  a  cause  of  death  at  specified  age  periods 
in  the  registration  area:  1907 — Continued. 

(C)  FROM  15  TO  29  YEARS,  INCLUSIVE. 


CAUSE  OF  DEATH. 


All  causes 

Typhoid  forer 

Tuberculosis  (all  forms) 

Tuberculosis  of  lungs 

Abdominal  tuberculosis 

Cancer 

Meningitis 

Heart  disease 

Pneumonia  (all  forms) 

Peritonitis 

Appendicitis 

Nephritis  and  Bright's  disease 

Puerperal  septicemia , 

Puerperal  convulsions 

Other  causes  incident  to  childbirth 

Violence 

All  other  causes , 


PER  CENT  OF  DEATHS  FROM  15 
TO  29  YEARS,  INCLUSIVE. 


Total. 


100.0 


7.4 

33.2 

30.5 

0.9 

0.9 

2.0 

4.3 

6.7 

1.1 

2.2 

3.9 

2.2 

1.1 

1.4 

16.8 

16.7 


Males.     Females. 


100.0 


8.6 
29.0 
26.5 
0.7 
0.7 
2.5 
4.0 
7.8 
0.6 
2.5 
3.4 


26.1 
14.9 


100.0 


5.9 
38.3 
35.3 
1.2 
1.1 
1.4 
4.7 
5.4 
1.7 
1.9 
4.6 
4.8 
2.5 
.3.0 
.5.6 
19.0 


(D)  FROM  30  TO  44  YEARS,  INCLUSIVE. 


CAUSE  OF  DEATH. 

PER  CENT  OF  DEATHS  FROM  30 
TO  44  YEARS,  INCLUSIVE. 

Total. 

Males. 

Females. 

All  causes 

100.0 

100.0 

100  0 

Typhoid  fever 

3.3 
25.6 
23.8 
4.5 
1.5 
2.2 
0.8 
1.0 
7.1 
8.8 
1.5 
0.8 
1.1 
7.5 
1.3 
0.6 
1.3 
13.1 
0.8 
17.1 

3.7 
26.2 
24.5 
2.3 
2.2 
2.1 
1.1 
0.9 
6.4 
9.9 
L8 
0.4 
1.2 
6.9 

2  7 

Tuberculosis  (all  forms) 

24  8 

Tuberculosis  of  lungs 

22  8 

Cancer 

7  7 

Alcoholism 

0  4 

Apoplexy 

2.3 

General  paralysis  of  insane 

0  4 

Endocarditis 

1  0 

Heart  disease 

8.1 

Pneumonia  (all  forms) 

7  2 

Cirrhosis  of  liver 

1  2 

Peritonitis 

1.4 

Appendicitis 

1.0 

Nephritis  and  Bright's  disease 

8  3 

Puerperal  septicemia 

3.2 

Puerperal  convulsions 

1.5 

Other  causes  incident  to  childbirth 

3.2 

Violence 

19.6 
0.7 
14,7 

4  1 

Ill-defined  causes 

0  9 

AU  other  causes 

20  6 

58  TUBERCULOSIS  IN   THE   UNITED   STATES. 

Table  7. — Relative  importance  of  tuberculosis  as  a  cause  of  death  at  specified  age  periods 
in  the  registration  area:  1907 — Continued. 

(£)  FROM  45  TO  59  YEARS,  INCLUSIVE. 


CArSE  OF  DEATH. 

PER  CENT  OF  DEATHS  FEOM  45 
TO  59  TEAES,   INCLUSIVE. 

Total. 

Males. 

Females. 

All  causes      .              

100.0 

100.0 

100.0 

Typhoid  fever 

1.3 
12.1  1 
11.0 
10.5 

1.6 

1.0 

6.5 

1.2 

0.8 

1.4 
12.5 

8.9 

0.8 

2.4 
11.0 

8.5 

1.1 
18.4 

1.4 

13.9 

12.8 

6.5 

1.2 

1.6 

5.8 

1.0 

1.0 

1.4 

12.0 

9.4 

0.7 

2.9 

10.9 

12.3 

1.0 

16.9 

1.1 

Tuberculosis  (all  forms) 

9.6 

8.5 

Cancer                            "^                              

16.2 

Diabetes   

2.0 

0.3 

7.5 

Paralysis 

1.6 

0.4 

1.4 

Heart  disease     

13.2 

8.2 

Diarrhea  and  enteritis 

1.0 

Cirrhosis  of  liver                     

1.7 

11.1 

3.0 

Ill-defined  causes                          

1.2 

20.4 

{F)  FROM  60  TO  74  YEARS,  INCLUSIVE. 


CAUSE  OF  DEATH. 

PER  CENT  OF  DEATHS  FEOM  60 
TO  74  TEAES,  INCLUSIVE. 

Total. 

Males. 

Females. 

100.0 

100.0 

100.0 

Influenza .          

2.3 

4.6 

4.1 

9.0 

L8 
10.5 

2.6 

1.3 
17.4 

1.0  ' 

2.1 

2.0 

8.7 

0.7 

1.3 

1.6 
11.5 

1.5  i 

1.9 

4.0 

1.5 
12.7 

1.8 
5.0 
4.5 
7.2 
1.5 

10.3 
2.6 
1.3 

17.8 
1.2 
2.5 
1.6 
8.2 
0.6 
1.1 
1.9 

12.5 
2.2 
1.6 
5.4 
1.5 

12.5 

3.0 

4.1 

Tuberculosis  of  lungs 

3.7 

Cancer        .                .        .        

11.0 

2.2 

10.7 

Paralysis                                                

2.8 

1.4 

Heart  disease 

16.9 

Angina  pectoris           .        .          

0.9 

1.7 

Bronchitis                                                                     ... 

2.4 

Pneumonia  (all  forms) .   .                     

9.4 

Gastritis 

0.9 

Diarrhea  and  enteritis 

1.5 

Cirrhosis  of  liver                            .                    

1.2 

Nephritis  and  Bright's  disease. 

10.3 
0.7 

Old  age - 

2.2 

Violence      

2.3 

1.4 

All  other  causes 

13.0 

TUBERCULOSIS  IN   THE   UNITED   STATES. 


59 


Table  7. — Relative  importance  of  tuberculosis  as  a  cause  of  death  at  specified  age  periods 
in  the  registration  area:  1907 — Continued. 

(O)  OVER  75  YEARS  OF  AGE. 


CAUSE  OF  DEATH. 


All  causes 

Influenza 

Dysentery 

Tuberculosis  (all  forms) 

Tuberculosis  of  lungs 

Cancer 

Apoplexy 

Paralysis 

Endocarditis 

Heart  disease 

Diseases  of  arteries 

Bronchitis 

Pneumonia  (all  forms) 

Gastritis 

Diarrhea  and  enteritis 

Nephritis  and  Bright's  disease 

Diseases  of  bladder 

•Other  diseases  of  genito-urinary  system 

Gangrene 

Old  age 

Violence 

Ill-defined  causes 

AU  other  causes 


PER  CENT  OF  DEATHS  AT  75 
YEAES  AND  OVER. 


Total.        Males.     Females. 


100.0 


4.0 
0.7 
1.4 
1.3 
4.4 

10.4 
3.5 
1.1 

15.4 
3.5 
3.6 
8.2 
1.0 
1.8 
8.2 
0.9 
1.1 
1.0 

13.6 
3.4 
1.9 

10.8 


100.0 


3.5 
0.6 
1.5 
1.3 
3.9 

10.3 
3.4 
1.1 

16.4 
3.9 
2.9 
7.1 
0.8 
1.5 
9.6 
1.6 
2.0 
1.2 

12.3 
3.4 
2.1 

10.9 


100.0 


4.5 
0.8 
1.4 
1.2 
4.9 

10.5 
3.6 
1.2 

14.0 
3.1 
4.2 
9.2 
1.1 
2.0 
6.8 
0.2 
0.3 
0.8 

14.8 
3.4 
1.8 

10.7 


Table  8.— Relative  importance  of  tuberculosis  as  a  cause  of  death  in  the  registration 

states:  1907. 


CAUSE  OF  DEATH. 

a 
o 

o 

_o 

o 
O 

4.5 

3 
_o 

'•(3 

i 

o 

o 

''B 

a 

a 
"3 

1 
3 

i 

£ 

3 
ft 

1 

o 

c3 

i 
> 
% 

a 
a 

a 
o 

c3 
=3 

3 
O 

o 

All  causes 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

100.0 

Typhoid  fever 

1.8 

3.6 

1.2 

98 

1.1 

2.5 

0  7 

1  6 

0  7 

1  1 

1  2 

3  1 

0  6 

2  0 

0.7 
0,9 

Whooping  cough 

0.5 

0.4 

0.8 

0.5 

0.6 

0.7 

0.6 

0.6 

0.9 

0.6 

0.5 

1.1 

0.9 

2.9 

Diphtheria  and  croup. 

1.2 

1.2 

1.5 

1.0 

1.0 

1.0 

1.4 

1.1 

1.3 

1.9 

1.7 

1.8 

1.4 

1.7 

0.6 

Tuberculosis  (all 

forms) 

15.0 

16.4 

9.8 

13.2 

10.2 

12.4 

10.5 

7.4 

7.6 

11.8 

11.3 

9.3 

11.2 

10,8 

8,1 

Cancer 

6.2 

3.1 

4.7 

4.6 

6.1 

3.8 

5.4 

4.8 

5.6 

3.9 

4.5 

3.8 

5.1 

4  0 

6,1 

Meningitis 

2.0 

1.9 

2.0 

1.4 

2.2 

1.4 

2.1 

1.3 

2.2 

1.8 

1.4 

1.1 

1.4 

1.5 

1.1 

Apoplexy 

4.3 

2.6 

6.2 

4.3 

6.7 

4.0 

5.7 

4.7 

6.7 

5.5 

4.9 

4.6 

5.3 

2,7 

7,5 

Paralysis 

1.2 

0.9 

0.7 

2.1 

1  6 

2  2 

0  9 

2  2 

1  9 

1  "^ 

0  7 

1  2 

0  7 

1  "^ 

0.9 
0.1 

"Convulsions  " 

0.4 

0.4 

0.8 

0.6 

0.7 

1.4 

0.8 

1.4 

0.7 

1.1 

0,6 

i.'r, 

n  4 

2  1 

Heart  disease 

10,9 

5,7 

9  S 

9  f) 

10  5 

7.7 

10  5 

in  9 

11  6 

7.5 

9.2 

8.0 

9.4 

4.9 

12.1 

Broncliitis 

1.3 

0.9 

2.0 

1.3 

1.6 

1.8     2.2 

2.1 

2.4 

1,7 

1  9 

1  7 

?,  0 

1  n 

2.4 

Pneumonia  (all  forms) 

7.9 

10.2 

9.2 

7.5 

9.5 

8.5 

9.2 

7.7 

7.9 

in.9 

11,8 

9.3 

10  0 

8  3 

10.4 

Diarrhea  and  enteritis 

3.4 

6.0 

7.9 

6.2 

4.1 

7.9 

7.3 

4.9 

4.9 

8.0 

7.6 

8,6 

8  9 

6  9 

4  6 

Cirrhosis  of  liver 

1.3 

0.6 

1.0 

0.8 

0.5 

0.6 

0.6 

0.9 

0.7 

1,1 

^.?, 

0,8 

0  9 

n  4 

0.7 

Nephritis  and  Bright's 
disease 

5.6 

4.8 

6.0 

5.6 

6.1 

7  5 

5  2 

4  6 

5  6 

7  1 

7  9 

5  6 

8  0 

3.7 
1.4 

6.0 

2  7 

Premature  birth 

1.5 

2.2 

2.5 

2.5 

1.8 

2.4 

2.5 

2.0 

2.7 

2,1 

?..?. 

?..n 

2  X 

Congenital  deoihty 

1.4 

1.6 

2.2 

2.1 

2.0 

3. 6     2.  7 

2.6 

2.6 

2.2 

1.9 

2..i 

1.6 

,3.1 

0.9 

Old  age 

1.9 

1.9 

1.7 

2.5 

4.4 

2.5 

2.1 

3.6 

4.1 

1.4 

1.5 

1.4 

1.S 

4  3 

3  7 

Violence 

10.8 

10.5 

7.2 

7.1 

5.3 

5.8 

6.1 

7.5 

5.2 

7.3 

6.9 

9.4 

6.8 

8.9 

5,4 

Ill-defined  causes 

1.7 

1  2 

1.5 

1.6 

3.6 

4.1 

2.2 

3.1 

2.7 

2.4 

1.0 

2.6 

1.3 

6.S 

1  8 

All  other  causes 

20.7 

23.6 

21.4 

23.6 

20.5 

18.2 

21.0 

24.9 

22.0 

19.4 

19.9 

20.2 

20.2 

21.3 

23.2 

Note.— This  table  is  based  upon  the  returns  of  the  deaths  that  actually  occurred  in  the  several  states, 
includmg  deaths  of  nonresidei'is.  Many  of  xhe  deatns  from  tuberculosis  reported  from  certain  states 
were  those  of  invalids  whose  illness  originated  elsewhere. 


60 


TUBEKCULOSIS  IN   THE   UNITED   STATES. 


Table  9. — Death  rates  from  tuberculosis  of  lungs,^  of  white  and  colored,  by  sex,  for  the 
registration  area  and  registration  states  {aggregate,  urban,  and  rural):  1900  and  1890. 


Registration  area 1900. . 

1890.. 

Registration  states 1900. . 

1890. . 

Cities 1900. . 

1890.. 

Rural 1900. . 

1890.. 


NUMBEE  OF  DEATHS  FEOM  TUBEKCULOSIS  OF  LUNGS  PEE 
100,000  OF  POPULATION. 


White. 


Total. 


173.5 
230.0 


170.5 
242.4 


197.8 
285.1 


131.6 

177.7 


Males. 


188.3 
240.1 


182.8 
250.1 


226.8 
308.1 


122.4 
165.1 


Females. 


158.8 
220.0 


158.3 
234.9 


169.9 
263.2 


141.2 
190.6 


Colored. 


Total. 


490.6 
546.1 


431.9 
529.2 


471.0 
600.1 


322.7 
365.2 


Males. 


527. 
578. 


463. 
589. 


525.8 


302. 
364. 


Females. 


455.1 
515.0 


401.6 
471.9 


420.2 
513.7 


345.2 
366.1 


1  Identical  with  consumption  as  shown  in  the  diagram;  the  latter  term  was  employed  in  the  Mor- 
tality Statistics  of  the  Census  up  to  the  close  of  the  census  year  1899-1900. 

Table  10. — Death  rates  from  tuberculosis  of  lungs,^  by  conjugal  condition,  at  certain  age 
periods  in  the  registration  area:  1900. 


NXJMBEE  OF  DEATHS  FEOM  TU^EECULOSIS  OF  LUNGS  (IN  THE  EEGISTEATION  AEEA) 
PEE  100,000  OF  POPULATION. 

CONJUGAL  CONDI- 
TION. 

15  years  and  over. 

15  to  44  years. 

45  to  64  years. 

65  years  and  over. 

Males. 

Females. 

Males. 

Females. 

Males. 

Females. 

Males. 

Females. 

Single 

309.8 
215.5 

225.2 
216.4 

292.2 
208.3 
667.0 

223.4 
237.6 
356.7 

565.3 
223.1 

487.4 

235.6 
153.7 
189.3 

604.1 
244.2 
312.0 

296.0 

236.1 

Widowed 

465.0  1        235.1 

213.2 

1  Identical  with  consumption  as  shown  in  the  diagram;  the  latter  term  was  employed  in  the  Mor- 
tality Statistics  of  the  Census  up  to  the  close  of  the  census  year  1899-1900. 

Table  11. — Death  rates  from  tuberculosis  of  lungs  ^  and  other  important  causes  of  death,  by 
classes  of  occupations,  in  the  registration  states:  1900. 


NUMBEE  OF  DEATHS  PEE  100,000  OF  POPULATION,   OP  OCCXTPIED 

MALES,    10  YEARS   OF 

AGE  AND   OVEE 

(IN  THE 

EEGISTEATION 

STATES),  BY 

CLASS  OF  OCCUPATION. 

Agri- 

Per- 

Manu- 

culture, 

PEINCIPAL  CAUSE  OF  DEATH. 

Mer- 

Public 
enter- 
tain- 
ment. 

sonal 

Labor- 
ing and 
serv- 
ant. 

factur- 

trans- 

Profes- 
sional. 

Clerical 

and 
official. 

cantile 
and 

trad- 

service, 

police, 

and 

ing  and 
me- 
chan- 

porta- 
tion, 
and 

ing. 

mili- 

ical in- 

other 

tary. 

dustry. 

out- 
door. 

Malarial  fever 

6.9 

37.9 

7.4 

182.2 

22.2 

263.4 

3.8 
46.6 
7.5 
304.2 
18.1 
154.0 

3.4 

28.3 

5.5 

165.8 

19.4 

17L5 

3.4 
27.3 
10.2 

268.5 
15.9 

192.3 

8.7 
38.2 

6.7 
254.8 

8.7 
144.8 

5.4 
51.1 

6.6 
376.8 

7.9 
199.9 

4.7 

29.4 

6.8 

262.1 

11.2 

172.6 

4.5 

32.8 

9.0 

Tuberculosis  of  lungs 

147.2 

13.3 

Diseases  of  nervous  system 

221.3 

176.8 
143.8 
94.0 

134.7 
138.7 
94.2 

145.5 
133.4 
85.9 

143.4 
166.1 
184.3 

126.0 
148.2 
76.5 

192.5 
249.2 
110.2 

150.0 
138.9 
75.5 

211.1 

140.0 

Diseases  of  digestive  system 

91.0 

Diseases  of  urinary  system 

ioa4 

138.0 

140.9 

172.9 

145.5 

167.3 

134.6 

145.5 

Diseases  of  bones  and  joints 

4.9 

3.5 

2.2 

2.3 

2.7 

6.0 

3.2 

3.6 

Violence ...         

77.3 
51.7 

79.8 
37.7 

66.2 
52.0 

88.8 
35.3 

111.3 
42.9 

240.8 
66.5 

108.8 
53.3 

158.6 

69.2 

1  Identical  with  consumption  as  shown  in  the  diagram;  the  latter  term  was  employed  in  the  Mor- 
tality Statistics  of  the  Census  up  to  the  close  of  the  census  year  1899-1900. 


z 
o 

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CONSUMPTION 

NUMBER  OF  DEATHS  PER  100,000  OF  POPULATION 

BY  CONJUGAL  CONDITION  AND  AGE  PERIODS 

REGISTRATION  AREA:  I900 

15  YEARS  AND  OVER 


MALES  FEMALES 

TOO  eOO   50O  400  300  200   100   O   100  200  300  400  500_  600__700 


SINGLE 

MARRIED 

WIDOWED 


SINGLE 

MARRIED 

WIDOWED 


SINGLE 

MARRIED 

WIDOWED 


SINGLE 

MARRIED 

WIDOWED 


65  YEARS  AND  OVER 


45  TO  64  YEARS 


15  TO  44  YEARS 

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CONSUMPTION 

NUMBER   OF  DEATHS   PER  lOO.OQO  OF  POPULATION 

AMONG  PERSONS  10  YEARS  OF  AGE  AND  UPWARD 

IN  SPECIFIED  QCCyPATiONS:   1300 


OCCUPATION 

MARBLE  AND  STONE  CUTTERS 
CIOARMAKERS  AND  TOBACCO  WOgKERO 
COMPOSITORS,  PRINTERS,  AMD  PfSESSMEK 
SERVANTS 

BOOKKEEPERS,  CLERKS,  AND  COPYISTS 
LASORERS  (NOT  ACRICULTURAU 
TIWNERS  and  TINWARE  MAKERS 
CABINETMAKERS  AND  UPHOLSTERERS 
musicians  AND  TEACHERS  OF  MUSIC 
BARBERS  AND  HAIRDRESSERS 
SAILORS.  PILOTS,  FISHERMEN,.  AND  OYSTERkIeM 
PAINTERS,  GLAZIERS,  AND  VARNISHER3 
LEATHER  MAKERS 
APOTHECARIES.  PHARMACISTS,  ETC 
COOPERS 

PLUMBERS  AND  CAS  AND  STEAM  FITTERS 
MASONS  IBRICK  AND  STONE) 
BUTCHERS 

SALOON  AND  RESTAURANT  KEEPERS 
LIVERY  STABLE  KEEPERS  AND  HOSTLERS 
DRAYMEN,  HACKMEN,  TEAMSTERS,  ETC. 
BOATMEN  AND  CANALMEN 
BREWERS,  DISTILLERS,  AND  RECTIFE.SS 
JANITORS  AND  SEXTONS 
HUCKSTERS  ANP  PEDDLERS 
BAKERS  AND  CONFECTIONERS- 
IRON  AND  STEEL  WORKE!^ 
CARPENTERS  AND  JOINERS 
ENGINEERS  AND  FIREMEI* 
LEATHER  WORKERS 
TAILORS 
BLACKSMITHS 

HOTEL  'AND  BOARDING  HOUSE  KEEPEHS 
MILL  AND  FACTORY  OPERATIVES  ITEXTILESt 
MILLERS  IFLOUR  AND  GRIST)- 
MACHINISTS 

ARCHITECTS.  ARTISTS,  TEACHERS  OF  ART,  ETO, 
JOURNALISTS 

GARDENERS.  FLORISTS.  AND  NURSERYMEN 
PHYSICIANS  ANT)  SURGEONS 
MERCHANTS  AND  DEALERS 
SCHOOL  TEACHERS 
LAWYERS 

POUCEMEN,  WATCHMEN,  AND  OETECtfvES 
BOOT  AND  SHOE  MAKERS 
COLLECTORS,  AUCTIONEERS.  AND  AGENTS 
STEAM  RAILROAD  EMPLOYEES 
CLERGYMEN 

MINERS  AND  QUARRYMEN 

FARMERS,  PLANTERS.  AND  FARM  LABORERS 
tUMBERMEN  AND  RAFTSMEN 
BANKERS,  BROKERS.  «iid  OFFICIALS  t><  COMPANIES 


SERVANTS 

TELEGRAPH  AND  TELEPHONE  OPERATOftS 

BOOKKEEPERS.  CLERKS,  AND  COPYISTS 

MILL  AND  FACTORY  OPERATIVES  (TEXTILES) 

DRESSMAKERS  A.ND  SEAMSTRESSES 

SCHOOL  TEACHERS 

MURSES  AND  MIONVIVES 

LAUNDRESSES 


MALE 


TUBEECULOSIS   IN   THE   UNITED   STATES. 


65 


Table  12. — Death  rates  from  tuberculosis  of  lungs  ^for  certain  occupations  of  each  sex,  in 

the  registration  states:  1900. 


OCCUPATION. 


MALES. 

Marble  and  stone  cutters 

Cigannakers  and  tobacco  workers 

Compositors,  printers,  and  pressmen 

Servants 

Bookkeepers,  clerks,  and  copyists 

Laborers  (not  agricultural) 

Tinners  and  tinware  makers 

Cabinetmakers  and  upholsterers 

Musicians  and  teachers  of  music 

Barbers  and  hairdressers 

Sailors,  pilots,  fishermen,  and  oystermen 

Painters,  glaziers,  and  varnishers 

Leather  makers 

Apothecaries,  pharmacists,  etc 

Coopers 

Plumbers,  and  gas  and  steam  fitters 

Masons  (brick  and  stone) 

Butchers 

Saloon  and  restaurant  keepers 

Livery  stable  keepers  and  hostlers 

Draymen,  hackmen,  teamsters,  etc 

Boatmen  and  canalinen 

Brewers,  distillers,  and  rectifiers 

Janitors  and  sextons 

Hucksters  and  peddlers 

Bakers  and  confectioners 

All  occupied  males 

Iron  and  steel  workers 

Carpenters  and  joiners 

Engineers  and  firemen  (not  locomotive) 

Leather  workers 

Tailors 

Blacksmiths 

Hotel  and  boarding  house  beepers 

Mill  and  factory  operatives(textiles) 

Millers  (flour  and  grist) 

Machinists 

Architects,  artists,  teachers  of  art,  etc 

Journalists 

Gardeners,  florists,  nurserymen,  and  vine  growers 

Physicians  and  surgeons 

Merchants  a  nd  dealers 

School  teachers 

Lawyers 

Policemen,  watchmen,  and  detectives 

Boot  and  shoe  makers 

Collectors,  auctioneers,  and  agents 

Steam  railroad  employees 

Clergymen 

Miners  and  quarrymen 

Farmers,  planters,  and  farm  laborers 

Lumbennen  and  raftsmen 

Bankers,  brokers,  and  officials  of  companies 

FEMALES. 

Servants 

Telegraph  and  telephone  operators 

Bookkeepers,  clerks,  and  copyists 

All  occupied  females 

Mill  and  factory  operatives  (textiles) 

Dressmakers  and  seamstresses 

School  teachers 

Nurses  and  mid  wives 

Laundresses 


1  Identical  with  consumption  as  shown  in  the  diagram;  the  latter  term  was  employed  in  the  Mor- 
tality Statistics  of  the  Census  up  to  the  close  of  the  census  year  1899-1900. 

53046—08 5 


66 


TUBERCULOSIS   IN   THE   UNITED   STATES. 


Table  13. — Death  rates  from  all  forms  of  tuberculosis  in  the  registration  area,  its  main 
subdivisions,  the  registration  states,  and  cities  of  100,000  population  or  over  in  1900,  for 
each  year  since  the  beginning  of  the  annual  reports  on  mortality  statistics:  1900  to  1907. 


NUMBER  OF  DEATHS  FROM  ALL  FORMS  OF 
100,000  OF  POPULATION. 

TUBERCULOSIS 

PER 

AEEA.. 

Annual 

average: 

1901  to 

1905. 

1900 

1901 

1902 

1903 

1904 

1905 

1906 

1907 

The  registration  area 

193.2 
213.0 
18L5 
211.5 
143.5 
214.5 

(1) 

(.') 

170.1 

177.3 

166.3 

(') 

193.4 
103.  2 
154.6 
192.6 

200.0 

(') 

216.0 

(') 
139.8 

328.0 
459.4 
200.3 
310.1 
177.7 

205.0 
233.7 
35L7 
266.8 
250.5 

189.6 
203.5 
129.6 
133.5 
132.5 

213.4 

79.3 

224.7 

114.7 

247.8 
268.2  1 
20.5.2  ! 
149.7 

248.0  ' 
.561.2  ' 

223. 1 
234.5  . 
164.8 
215.  4  . 

201.2 
221.8 
194.5 
230.2 
153.5 
213.5 

(I) 

(^) 

189.9 

187.9 

182.5 

(1) 
212.3 
106.8 
170.3 
205.1 

214.2 

231.0 

(1) 
154.  5 

330.2 
397.4 
212.9 
326.1 
184.6 

232.9 

227.6 
369.2 
254.6 
288.1 

206.0 
230.5 
130.9 
157.4 
150.2 

205.2 

92.2 

205.7 

119.9 

283.4 
276.0 
221.5 
134.5 

273.4 
'284.2 
250.  8 
292.9 
211.1 
235.8 

196.8 
216.3 
189.2 
221.6 
149.6 
210.9 

(') 

(1) 
181.8 
182.7 
181.9 

(1) 
202.8 
103.5 
165.3 
192.4 

211.0 

(1) 
222.2 

(1) 
15L7 

334.5 
430.9 

217.7 
330.1 
168.0 

204.0 
218.1 
339.5 
270.9 
271.9 

164.7 
221.8 
127.7 
155.2 
142.5 

194.2 

87.2 
207.8 
110.2 

245.2 
254.3 
199.2 

148.4 

261.4 
557.0 
234.0 
252.3 
196.3 
222.9 

184.7 
204.4 
173.5 
203.6 
136.0 
205.2 

(1) 

165.0 
170.9 

167.7 

189.5 
98.1 
150.5 
176.1 

190.7 

(1) 
209.3 

(1) 
136.5 

324.9 
437.1 
217.1 
280. 9 
165.7 

186. 1 
210.1 
352.9 
252.6 
249.9 

186.3 
188.9 
131.6 
128.0 
130.7 

183.6 
100.1 
201.0 
113.9 

234.7 
254.3 
194.0 
135.3 

240.6 
538.6 
219.6 
227.1 
160. 9 
211.8 

189.0 
209.4 
176.6 
207.3 
137.7 
211.6 

(1) 

(1) 
167.3 
171.4 
153.8 

(1) 
183.1 
101.4 
146.0 
189.1 

195.9 

(1) 
125.7 

(1) 
134.9 

339.4 
440.5 
190.2 
303.9 
182.2 

208.9 
233.7 
349.  3 
257.7 
239.7 

203.1 
203.  6 
121.2 
145.9 
114.5 

216.7 

62.4 

211.2 

127.0 

245.3 
273.1 
189.0 

145.7 

245. 3 
564.7 
221.1 
232.3 
146.2 
208.3 

201.5 
222.4 
187.8 
218.2 
148.7 
226.6 

(1) 

(1) 
164.9 
191.4 
172.8 

(') 
199.3 
107.9 
159.8 
207.1 

204.  7 

(') 
209.2 

(') 
135.0 

319.5 
493.5 
191.7 
317.1 
184.8 

234.9 
260.0 
370.0 
283.4 
248.4 

223.6 
198.1 
142.0 
129.9 
132.0 

250.9 

72.5 

252.1 

123. 1 

283.1 
281.0 
234.0 
159.4 

253.1 
584. 4 
234. 1 
234.4 
163.1 
186.7 

193.6 

212.2 
180.4 
207.2 
145.  3 
217.4 

(1) 

(') 
171.8 
170.2 
1.55.  5 

(') 
192.7 
104.  9 
151.4 
197.5 

197.9 

213.9 

0) 

141. 2 

322.2 
490.3 
186.5 

318. 3 
185.8 

189.9 

244.8 
340.2 
269.3 
243.1 

170.2 
205.3 
125.3 
112.2 
142.6 

219.8 
75.3 

248.5 
99.6 

230.4 
276.4 
208.9 
159.2 

240.5 
558.  5 
208.1 
227.6 
160.8 
246.8 

184.2 
210.0 
180.0 
213.9 
140.4 
20L5 

267.1 
277.6 
159.3 
165.  3 
158.0 

204.6 
183.  7 
106.4 
149.8 
199.1 

2C0.6 
155.  6 
202.  3 
97.6 
133.6 

r-) 

50L6 
181.4 
291.5 
187.2 

199.4 
228.6 
318.0 
270.9 
237.5 

156.7 
189.9 
136.1 
123.4 
126.6 

196.3 

94.9 

216.9 

104.7 

260.5 
298.0 
242.0 
155.0 

248.3 
534.9 
214.0 
239.4 
165.8 
275.2 

183.6 

Registration  cities. .           .      ... 

207.4 

Registration  states 

179.6 

Cities  in  registration  states 

Rural  part  of  registration  states . 
Registration  cities  in  other  states. 

Registration  states: 

California                            .  -  - 

210.9 
142.5 
199.7 

278.9 

Colorado 

289.4 

Connecticut 

167.2 

Indiana                               

165.4 

Maine                                   

168.8 

Maryland                            

200.2 

Massachusetts 

183.4 

Michigan                             .  . . 

103.5 

New  Hampshire 

130.  5 

New  Jersey 

196.4 

New  York 

198.5 

Pennsylvania 

153.9 

Rhode  Island  ..                  

200.9 

South  Dakota .                   

105.1 

Veimont ... 

131. 2 

Registration    cities    of    100,000 
population  or  over  in  1900: 
San  Franei'^co,  Cal 

n 

Denver,  Colo ... 

486.6 

New  Haven,  Conn 

209.8 

Washington,  D.  C 

280.0 

Chicago,  111 

191.6 

Indianapolis,  Ind 

240.7 

Louisville,  Ky.. 

214.7 

New  Orleans,  La 

332.0 

Baltimore,  Md... 

2C3.2 

Boston,  Mass 

221.1 

Fall  River,  Mass .               ... 

195.1 

Worcester,  Mass. . 

180.3 

Detroit,  Mich 

123.8 

Minneapolis,  Minn. .           ... 

119.0 

St.  Paul,  Minn. 

154.3 

Kansas  City,  Mo 

207.6 

St.  Joseph,  Mo . 

87.1 

St.  Louis,  Mo. .. 

195.6 

Omaha,  Nebr 

112.7 

Jersey  City,  N.  J . .   . 

261.5 

Newark,  N.  J 

291.6 

Paterson,  N.J 

173.6 

Buffalo,  N.Y 

152.6 

New  York,  N.Y 

242.2 

Bronx  borough 

512.6 

Brooklyn  borough 

Manhattan  borough 

Queens  borough 

204. 8 
238.1 
162.2 

Richmond  borough 

223.1 

1  Nonregistration. 

-  Population  not  estimated  for  1906  and  1907. 

3  For  this  year,  but  not  for  subsequent  years,  many  deaths  from  tuberculosis  in  hospitals  situated 
in  Bronx  borough  were  transferred  to  Manhattan  and  other  boroughs  whence  the  cases  originated. 


TUBERCULOSIS  IN   THE   UNITED  STATES. 


67 


Table  13. — Death  rates  from  all  forms  of  tuberculosis  in  the  registration  area,  its  main 
subdivisions,  the  registration  states,  and  cities  of  100,000  population  or  over  in  1900,  for 
each  year  since  the  beginning  of  the  annual  reports  on  mortalitrj  statistics:  1900  to  1907 — 
Continued. 


Eegistration  cities  of  100,000  pop- 
ulation or  over  in  1900— Cont'd. 

Rochester,  N.  Y 

Syracuse,  N.  Y 

Cincinnati,  Ohio 

Cleveland,  Ohio 

Columbus,  Ohio 

Toledo,  Ohio 

Allegheny,  Pa 

Philadelphia,  Pa 

Pittsburg,  Pa 

Scranton,  Pa 

Providence,  R.I 

Memphis,  Tenn 

Milwaukee,  Wis 


NUHBEB  OF  DEATHS  FROM  ALL  FORMS  OF  TUBERCTn.OSIS  PER 
100,000  OF  POPULATION. 


Annual 

average: 

1901  to 

1905. 


154.0 
153.5 
273.5 
138.8 
229.0 

150.5 
163.3 
2'JO.ti 
171.3 

98.4 
246.0 
234.9 
149.4 


1900 


161.1 

184. 5 
224.0 
132.8 
229.4 

148.6 
183.2 

239. 6 
140.8 

106.8 
279.1 
256.1 
151.1 


1901 


167.2 
174.3 
266.1 
122.1 
225.8 

140.6 
157.6 
233.2 
156.4 

102.3 
259.7 
240.4 
153.3 


1902 


128.3 
135.9 
235.1 
129.1 
201.3 

135.9 
173.3 
222.7 
159.8 

92.3 
251.1 
269.4 
119.2 


1903 


144.6 
148.7 
268.5 
144.3 
228.1 

129.5 
156.5 
246.1 
171.6 

102.9 
268.7 
190.9 
151.0 


1904 


160.2 
170.8 
305.8 
150.5 
257.2 

180.0 
173.0 
262.8 
181.6 

104.2 
232.4 
231.6 
159.9 


1905 


168.7 
138.3 
290.3 
140.5 
230.8 

163.6 
156.1 
237.5 
185.1 

90.4 
220.5 
243.3 
162.7 


1906 


166.4 
146.4 
307.3 
144.0 
242.0 

152.5 
190.0 
259.5 
160.0 

84.3 
205.1 
214.4 
151.0 


1907 


155.2 
149.2 
266.8 
149.0 
232.  G 

168.8 
156.5 
253.5 
139.1 

95.6 
201.6 
199.5 
138.3 


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